Provider Demographics
NPI:1790093417
Name:KEEN, ERICA LORRAINE (AA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LORRAINE
Last Name:KEEN
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 WILD HORSE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-6700
Mailing Address - Country:US
Mailing Address - Phone:907-590-0689
Mailing Address - Fax:
Practice Address - Street 1:3830 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7530
Practice Address - Country:US
Practice Address - Phone:907-452-1575
Practice Address - Fax:907-455-1460
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AK36334246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health