Provider Demographics
NPI:1912308362
Name:KEOGH, MARIE (MPH, RD, CDN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:
Last Name:KEOGH
Suffix:
Gender:F
Credentials:MPH, RD, CDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12335 82ND RD
Mailing Address - Street 2:APT 4K
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1611
Mailing Address - Country:US
Mailing Address - Phone:516-978-2190
Mailing Address - Fax:
Practice Address - Street 1:12335 82ND RD
Practice Address - Street 2:APT 4K
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1611
Practice Address - Country:US
Practice Address - Phone:516-978-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006939-1133V00000X
NYL-104888174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN