Provider Demographics
NPI:1245039452
Name:KIRSTINE, KEITH DYLAN
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DYLAN
Last Name:KIRSTINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:CREIGHTON
Mailing Address - State:NE
Mailing Address - Zip Code:68729-2903
Mailing Address - Country:US
Mailing Address - Phone:402-360-1280
Mailing Address - Fax:
Practice Address - Street 1:601 CLARK AVE
Practice Address - Street 2:
Practice Address - City:CREIGHTON
Practice Address - State:NE
Practice Address - Zip Code:68729-2903
Practice Address - Country:US
Practice Address - Phone:402-360-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE372500000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider