Provider Demographics
NPI:1366926255
Name:ZACKARY, KLYSHEE BRIONNE (RN)
Entity type:Individual
Prefix:
First Name:KLYSHEE
Middle Name:BRIONNE
Last Name:ZACKARY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2077 VALLEY FORGE DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3031
Mailing Address - Country:US
Mailing Address - Phone:937-250-9288
Mailing Address - Fax:
Practice Address - Street 1:2077 VALLEY FORGE DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45440-3031
Practice Address - Country:US
Practice Address - Phone:937-250-9288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.168149.MEDSIV164W00000X
OHRN.499980163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse