Provider Demographics
NPI:1649941931
Name:KEITH, MICHELE (RN)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL SPECIAL WARFARE COMMAND 2000 TRIDENT WAY BLDG 624
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92155-5599
Mailing Address - Country:US
Mailing Address - Phone:559-381-1279
Mailing Address - Fax:
Practice Address - Street 1:2000 TRIDENT WAY BLDG 624
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5599
Practice Address - Country:US
Practice Address - Phone:559-381-1279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-26
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001252061163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse