Healthcare Provider Details

I. General information

NPI: 1689887101
Provider Name (Legal Business Name): KESHIA MILLSAPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3469 NEW HIGHWAY 68
MADISONVILLE TN
37354
US

IV. Provider business mailing address

P.O. BOX 38 3469 HIGHWAY 68
MADISONVILLE TN
37354
US

V. Phone/Fax

Practice location:
  • Phone: 142-344-2399
  • Fax: 423-442-9468
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN0000150194
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: