Provider Demographics
NPI:1396733739
Name:KEITH, MARY JEANNE (RN, CNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JEANNE
Last Name:KEITH
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1718 W 66TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2138
Mailing Address - Country:US
Mailing Address - Phone:612-861-1080
Mailing Address - Fax:612-866-0459
Practice Address - Street 1:401 CARLSON PARKWAY
Practice Address - Street 2:CP340
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5387
Practice Address - Country:US
Practice Address - Phone:952-992-3604
Practice Address - Fax:612-866-0459
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD136908-23363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN553215900Medicaid
MN553215900Medicaid
MNR94984Medicare UPIN