Provider Demographics
NPI:1659915775
Name:WALL, KEELIN SWEENEY (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:KEELIN
Middle Name:SWEENEY
Last Name:WALL
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:KEELIN
Other - Middle Name:MAIRE WHITE
Other - Last Name:SWEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:350 HERITAGE WAY STE 2100
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3167
Mailing Address - Country:US
Mailing Address - Phone:406-257-8992
Mailing Address - Fax:
Practice Address - Street 1:LOGAN HEALTH
Practice Address - Street 2:310 SUNNYVIEW LANE
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-0127
Practice Address - Country:US
Practice Address - Phone:406-257-8992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT47158363LC0200X
MTNUR-APRN-LIC-147158363LA2100X
MT147158363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care