Provider Demographics
NPI:1619327129
Name:KEATLEY, SCOTT (RD, CDN)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:KEATLEY
Suffix:
Gender:M
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110943
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-0943
Mailing Address - Country:US
Mailing Address - Phone:800-571-8276
Mailing Address - Fax:888-974-0289
Practice Address - Street 1:596 BROADWAY
Practice Address - Street 2:STE 302
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3396
Practice Address - Country:US
Practice Address - Phone:800-571-8276
Practice Address - Fax:888-974-0289
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009107133N00000X, 133VN1005X, 133VN1006X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6004111OtherAETNA
NYNU009107OtherHEALTHFIRST
NY009107OtherNYS REGISTRATION
NY06090442OtherBLUE CROSS BLUE SHIELD
NY75762436OtherCIGNA