Healthcare Provider Details

I. General information

NPI: 1750180568
Provider Name (Legal Business Name): KEYONTAE GWALTNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 BLACKLICK EASTERN RD
PICKERINGTON OH
43147-8235
US

IV. Provider business mailing address

1851 N ERIE ST
TOLEDO OH
43611-3830
US

V. Phone/Fax

Practice location:
  • Phone: 614-726-7359
  • Fax:
Mailing address:
  • Phone: 732-430-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: