Provider Demographics
NPI:1518533058
Name:KING, KEITH TISHEEM (FNP-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:TISHEEM
Last Name:KING
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:888-472-0043
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:5070 INTERNATIONAL BLVD STE 131
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6007
Practice Address - Country:US
Practice Address - Phone:843-402-5053
Practice Address - Fax:843-724-1325
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25025363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care