Provider Demographics
NPI:1134555170
Name:POLLARD, KEISHA RENEE (LPN)
Entity type:Individual
Prefix:MS
First Name:KEISHA
Middle Name:RENEE
Last Name:POLLARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17204 WALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-1548
Mailing Address - Country:US
Mailing Address - Phone:216-965-2969
Mailing Address - Fax:
Practice Address - Street 1:17204 WALDEN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-1548
Practice Address - Country:US
Practice Address - Phone:216-965-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401300550911376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2707879Medicaid