Provider Demographics
NPI:1144897646
Name:WILEY, KEOSHA LYNETTA
Entity type:Individual
Prefix:
First Name:KEOSHA
Middle Name:LYNETTA
Last Name:WILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18930 PASNOW AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119
Mailing Address - Country:US
Mailing Address - Phone:440-454-0413
Mailing Address - Fax:
Practice Address - Street 1:18930 PASNOW AVE
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119
Practice Address - Country:US
Practice Address - Phone:440-454-0413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163012164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse