Provider Demographics
NPI:1922000280
Name:KECK, MADELYN M (ARNP)
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:M
Last Name:KECK
Suffix:
Gender:F
Credentials:ARNP
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 844737
Mailing Address - Street 2:ATTN: IPM CREDENTIALING
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4737
Mailing Address - Country:US
Mailing Address - Phone:903-416-1726
Mailing Address - Fax:903-416-1701
Practice Address - Street 1:302 N INDEPENDENCE STREET
Practice Address - Street 2:SUITE 700
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4046
Practice Address - Country:US
Practice Address - Phone:580-249-3066
Practice Address - Fax:580-234-5385
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0039619363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK500017031OtherRAILROAD MEDICARE
OK444342284001OtherBLUE CROSS
OK100088110AMedicaid
OK100088110AMedicaid