Healthcare Provider Details

I. General information

NPI: 1376164608
Provider Name (Legal Business Name): KESHAUN NECOLE HARDING FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3742 BEECH ST
FLOSSMOOR IL
60422-1004
US

IV. Provider business mailing address

3742 BEECH ST
FLOSSMOOR IL
60422-1004
US

V. Phone/Fax

Practice location:
  • Phone: 708-802-2620
  • Fax: 844-230-8586
Mailing address:
  • Phone: 708-802-2620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.021293
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041387946
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: