Provider Demographics
NPI:1275043028
Name:MCKEEN, STEPHANIE ALEXANDRA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALEXANDRA
Last Name:MCKEEN
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 1:10611 GOLDEN EAGLE TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-4280
Mailing Address - Country:US
Mailing Address - Phone:651-231-2314
Mailing Address - Fax:
Practice Address - Street 1:10611 GOLDEN EAGLE TRL
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-4280
Practice Address - Country:US
Practice Address - Phone:651-231-2314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer