Healthcare Provider Details

I. General information

NPI: 1376221887
Provider Name (Legal Business Name): KEISHA LATRICE LIDE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10616 METROMONT PKWY STE 210
CHARLOTTE NC
28269-7670
US

IV. Provider business mailing address

PO BOX 360
SYLVA NC
28779-0360
US

V. Phone/Fax

Practice location:
  • Phone: 704-774-6569
  • Fax: 855-308-2340
Mailing address:
  • Phone: 888-339-6065
  • Fax: 828-538-4441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5020183
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5020183
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: