Provider Demographics
NPI:1164775649
Name:KEATLEY, GINA ANGEL (MBA, CDN)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:ANGEL
Last Name:KEATLEY
Suffix:
Gender:F
Credentials:MBA, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 HOPKINS ST APT 3L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-5021
Mailing Address - Country:US
Mailing Address - Phone:800-571-8276
Mailing Address - Fax:888-974-0289
Practice Address - Street 1:596 BROADWAY
Practice Address - Street 2:SUITE 302
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3396
Practice Address - Country:US
Practice Address - Phone:800-571-8276
Practice Address - Fax:888-974-0289
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-20
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007594133N00000X, 133VN1005X, 133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
P4751979OtherOXFORD
PH56000OtherELDERPLAN
NYNU007594-B85OtherHEALTHFIRST
003588303001OtherUNITED HEALTHCARE NY COMMUNITY
0000358830304OtherUNITED HEALTHCARE
3343362OtherGHI
01901192OtherHEALTHPLUS AMERIGROUP
126DB3OtherBLUE CROSS BLUE SHIELD
SEIU147289Other1199SEIU
2305722OtherCIGNA
9388910OtherAETNA
P4751979OtherOXFORD