Provider Demographics
NPI:1659923043
Name:QUEELEY, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:QUEELEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94708-1603
Mailing Address - Country:US
Mailing Address - Phone:510-423-2875
Mailing Address - Fax:
Practice Address - Street 1:250 BON AIR RD UNIT B
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-473-6829
Practice Address - Fax:415-473-4113
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA849882163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice