Provider Demographics
NPI:1053683664
Name:KEITH, MARY ANN A (CHA III)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:A
Last Name:KEITH
Suffix:
Gender:F
Credentials:CHA III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 MOSES POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:ELIM
Mailing Address - State:AK
Mailing Address - Zip Code:99739
Mailing Address - Country:US
Mailing Address - Phone:907-890-3311
Mailing Address - Fax:907-890-2280
Practice Address - Street 1:69 MOSES POINT ROAD
Practice Address - Street 2:
Practice Address - City:ELIM
Practice Address - State:AK
Practice Address - Zip Code:99739
Practice Address - Country:US
Practice Address - Phone:907-890-3311
Practice Address - Fax:907-890-2280
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12-1168-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK12-1168-IIIOtherCHA III