Healthcare Provider Details

I. General information

NPI: 1841522000
Provider Name (Legal Business Name): KEISHA TULLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 02/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3054 W POPLAR RIDGE RD NW
MALTA OH
43758-9682
US

IV. Provider business mailing address

3054 W POPLAR RIDGE RD NW
MALTA OH
43758-9682
US

V. Phone/Fax

Practice location:
  • Phone: 740-973-0058
  • Fax: 740-962-3351
Mailing address:
  • Phone: 740-973-0058
  • Fax: 740-962-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number319249
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: