Healthcare Provider Details

I. General information

NPI: 1952132508
Provider Name (Legal Business Name): KEISHA BLAIR NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 ELTON ST
BROOKLYN NY
11239-5831
US

IV. Provider business mailing address

1202 ELTON ST
BROOKLYN NY
11239-5831
US

V. Phone/Fax

Practice location:
  • Phone: 718-307-5735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number354762
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF354762
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: