Provider Demographics
NPI:1689827164
Name:KEANE, ELIZABETH W (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:W
Last Name:KEANE
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:YACC, 3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-638-6100
Practice Address - Fax:617-638-6179
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MARN280089363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110097630AMedicaid