Provider Demographics
NPI:1023707205
Name:KEASTER, MATTIE (APRN)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:KEASTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 W FAULKNER ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4519
Mailing Address - Country:US
Mailing Address - Phone:870-314-1314
Mailing Address - Fax:
Practice Address - Street 1:1646 HUTTIG HWY
Practice Address - Street 2:
Practice Address - City:STRONG
Practice Address - State:AR
Practice Address - Zip Code:71765-9780
Practice Address - Country:US
Practice Address - Phone:870-314-1314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR223445363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner