Provider Demographics
NPI:1700362662
Name:KEETON, KRISTEN NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:KEETON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:EAGLE ROCK
Mailing Address - State:MO
Mailing Address - Zip Code:65641-0206
Mailing Address - Country:US
Mailing Address - Phone:580-364-4041
Mailing Address - Fax:
Practice Address - Street 1:2200 IRONWOOD PL
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2610
Practice Address - Country:US
Practice Address - Phone:208-667-6486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1899225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist