Healthcare Provider Details

I. General information

NPI: 1194137117
Provider Name (Legal Business Name): KEELEY RUTH MIZELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2014
Last Update Date: 05/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41990 COOK ST STE 1004
PALM DESERT CA
92211-6105
US

IV. Provider business mailing address

41990 COOK ST STE 1004
PALM DESERT CA
92211-6105
US

V. Phone/Fax

Practice location:
  • Phone: 760-341-5570
  • Fax:
Mailing address:
  • Phone: 760-341-5570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number780536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: