Provider Demographics
NPI:1639544307
Name:TOHANNIE, KEANU BEN (CERTIFIED MEDICAL AS)
Entity Type:Individual
Prefix:
First Name:KEANU
Middle Name:BEN
Last Name:TOHANNIE
Suffix:
Gender:M
Credentials:CERTIFIED MEDICAL AS
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 600
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:928-283-2094
Mailing Address - Fax:928-283-2677
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0600
Practice Address - Country:US
Practice Address - Phone:928-283-2094
Practice Address - Fax:928-283-2677
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8L6X2B3376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide