Provider Demographics
NPI:1275122079
Name:KEEN, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:KEEN
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 1:259 SHERATON DR NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:259 SHERATON DR NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-2271
Practice Address - Country:US
Practice Address - Phone:330-605-1527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
OH261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental DisabilitiesGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000256299Medicaid