Provider Demographics
NPI:1699400143
Name:KEELY, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:KEELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6835
Mailing Address - Country:US
Mailing Address - Phone:810-410-6124
Mailing Address - Fax:
Practice Address - Street 1:207 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5941
Practice Address - Country:US
Practice Address - Phone:208-343-2079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0002836129Medicaid