Healthcare Provider Details

I. General information

NPI: 1053000869
Provider Name (Legal Business Name): NICOLETTE KEYS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N BECKLEY AVE PAVILLION III SUITE 363
DALLAS TX
75203
US

IV. Provider business mailing address

3031 OLIVER STREET APT #1402
DALLAS TX
75205
US

V. Phone/Fax

Practice location:
  • Phone: 214-305-8667
  • Fax:
Mailing address:
  • Phone: 512-363-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16771
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: