Provider Demographics
NPI:1619228251
Name:MIMS, KEATON LEIGH (MSN)
Entity Type:Individual
Prefix:MRS
First Name:KEATON
Middle Name:LEIGH
Last Name:MIMS
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2051 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5834
Mailing Address - Country:US
Mailing Address - Phone:843-573-2535
Mailing Address - Fax:843-573-2534
Practice Address - Street 1:2051 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5834
Practice Address - Country:US
Practice Address - Phone:843-573-2535
Practice Address - Fax:843-573-2534
Is Sole Proprietor?:No
Enumeration Date:2012-09-23
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCAPN.18027RX363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics