Provider Demographics
NPI:1114068657
Name:KEACH, HEATHER LYNNN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNNN
Last Name:KEACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 GARDINER DR
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7634
Mailing Address - Country:US
Mailing Address - Phone:631-647-5530
Mailing Address - Fax:
Practice Address - Street 1:252 ISLIP AVE
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3015
Practice Address - Country:US
Practice Address - Phone:631-581-6800
Practice Address - Fax:631-581-6814
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009233-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist