Provider Demographics
NPI:1184013534
Name:KEITH, MARA E (AGNP)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:E
Last Name:KEITH
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:E
Other - Last Name:LINDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8401 MEDICAL PLAZA DR
Mailing Address - Street 2:STE 365
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-8797
Mailing Address - Country:US
Mailing Address - Phone:704-944-0975
Mailing Address - Fax:704-943-3699
Practice Address - Street 1:8401 MEDICAL PLAZA DR
Practice Address - Street 2:STE 365
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8797
Practice Address - Country:US
Practice Address - Phone:704-944-0975
Practice Address - Fax:704-943-3699
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007439363LF0000X
NCKEIT-NR0GSV363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily