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General NPI Number Information
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NPI Number | 1386225001
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Entity Type | Individual
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Provider Name | KESHA PANTRY FNP
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Gender | Female
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Dates
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Enumeration Date | 04/15/2021
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 5308 13TH AVE STE 509
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City | BROOKLYN
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State | NY
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Zip | 11219-5198
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Country | US
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Telephone | 929-594-4494
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Fax | 718-299-6797
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Provider Business Mailing Address
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Address Line | 4941 NW 84TH AVE
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City | LAUDERHILL
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State | FL
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Zip | 33351-5555
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 694261
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | F347626
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License Number State | NY
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