Provider Demographics
NPI:1275012635
Name:CHARLES, KEENA DEANE
Entity Type:Individual
Prefix:MRS
First Name:KEENA
Middle Name:DEANE
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEENA
Other - Middle Name:D
Other - Last Name:PACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2614 E 21ST ST N STE 102
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2207
Mailing Address - Country:US
Mailing Address - Phone:316-214-1967
Mailing Address - Fax:855-631-0467
Practice Address - Street 1:2614 E 21ST ST N STE 102
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2207
Practice Address - Country:US
Practice Address - Phone:316-214-1967
Practice Address - Fax:855-631-0467
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS83-1206206OtherTAX IDENTIFICATION