Provider Demographics
NPI:1073365193
Name:MARK, KEELIANN LEIGH (DO)
Entity Type:Individual
Prefix:
First Name:KEELIANN
Middle Name:LEIGH
Last Name:MARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 SHORTER AVE NW STE 201
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-4256
Mailing Address - Country:US
Mailing Address - Phone:706-509-3300
Mailing Address - Fax:
Practice Address - Street 1:304 SHORTER AVE NW STE 201
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4256
Practice Address - Country:US
Practice Address - Phone:706-509-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program