Provider Demographics
NPI:1912512096
Name:KEENEY, KAITLIN M
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:KEENEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 MENDAKOTA CT
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1336
Mailing Address - Country:US
Mailing Address - Phone:651-270-1370
Mailing Address - Fax:
Practice Address - Street 1:6905 YORK AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2517
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6984363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily