Provider Demographics
NPI:1124780408
Name:KEATON, HEATHER MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:KEATON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S PARK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8541
Mailing Address - Country:US
Mailing Address - Phone:760-909-0539
Mailing Address - Fax:
Practice Address - Street 1:200 S PARK RD STE 200
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8541
Practice Address - Country:US
Practice Address - Phone:760-909-0539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018668363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner