Provider Demographics
NPI:1164553400
Name:KEENAN, KATHLEEN MATTHEWS
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MATTHEWS
Last Name:KEENAN
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 1:3851 ROSECRANS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3115
Mailing Address - Country:US
Mailing Address - Phone:619-692-8292
Mailing Address - Fax:
Practice Address - Street 1:4855 PINE ST
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3825
Practice Address - Country:US
Practice Address - Phone:619-697-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy