Provider Demographics
NPI:1003847567
Name:KEENAN, PAMELA DENISE (AUDIOLOGIST MA,CCCA)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:DENISE
Last Name:KEENAN
Suffix:
Gender:F
Credentials:AUDIOLOGIST MA,CCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:961 4 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8252
Mailing Address - Country:US
Mailing Address - Phone:616-455-9180
Mailing Address - Fax:616-574-0215
Practice Address - Street 1:4444 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-4600
Practice Address - Country:US
Practice Address - Phone:616-455-9180
Practice Address - Fax:616-574-0215
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000146231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI804784633Medicaid
MIP52186Medicare UPIN
MI804784633Medicaid
MIOM74090Medicare ID - Type UnspecifiedMEDICARE