Provider Demographics
NPI:1497522817
Name:LEETH, KEITH ALAN JR (RN)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:LEETH
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 STATE ROUTE 220
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9058
Mailing Address - Country:US
Mailing Address - Phone:740-600-0819
Mailing Address - Fax:
Practice Address - Street 1:1252 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-1852
Practice Address - Country:US
Practice Address - Phone:866-534-2639
Practice Address - Fax:800-480-7578
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.168157.MEDS-IV164W00000X
OHRN.543295163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0036897Medicaid