Healthcare Provider Details

I. General information

NPI: 1003649112
Provider Name (Legal Business Name): KIESHA LOCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 KURTZ AVE
DAYTON OH
45405-2716
US

IV. Provider business mailing address

20 KURTZ AVE
DAYTON OH
45405-2716
US

V. Phone/Fax

Practice location:
  • Phone: 937-248-1600
  • Fax:
Mailing address:
  • Phone: 326-467-5744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: