Provider Demographics
NPI:1619282217
Name:KEITH, SUSAN D (CFM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:KEITH
Suffix:
Gender:F
Credentials:CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6439
Mailing Address - Country:US
Mailing Address - Phone:910-350-0067
Mailing Address - Fax:910-350-0065
Practice Address - Street 1:200 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3416
Practice Address - Country:US
Practice Address - Phone:910-640-2939
Practice Address - Fax:910-640-3938
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFM02267225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter