Provider Demographics
NPI:1376521526
Name:KEHOE, DOREEN R (NP)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:R
Last Name:KEHOE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6413 WATERS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2711
Mailing Address - Country:US
Mailing Address - Phone:912-349-6624
Mailing Address - Fax:912-354-4694
Practice Address - Street 1:6413 WATERS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2711
Practice Address - Country:US
Practice Address - Phone:912-349-6624
Practice Address - Fax:912-354-4694
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN309755363L00000X
GARN206799363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP80367Medicare UPIN
GA202I503235Medicare PIN
CARN309755Medicaid