Provider Demographics
NPI:1679801419
Name:CHURCH, KEISHA R (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:R
Last Name:CHURCH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:D
Other - Last Name:HACKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1200 GRANADA ST
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-3026
Mailing Address - Country:US
Mailing Address - Phone:301-203-6462
Mailing Address - Fax:301-203-0317
Practice Address - Street 1:1200 GRANADA ST
Practice Address - Street 2:
Practice Address - City:ACCOKEEK
Practice Address - State:MD
Practice Address - Zip Code:20607-3026
Practice Address - Country:US
Practice Address - Phone:301-203-6462
Practice Address - Fax:301-203-0317
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR168546367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered