Healthcare Provider Details

I. General information

NPI: 1184629461
Provider Name (Legal Business Name): HEATHER MICHELLE KEENE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 MOUNTAIN VIEW AVE STE 400
LONGMONT CO
80501-3128
US

IV. Provider business mailing address

1925 MOUNTAIN VIEW AVE STE 400
LONGMONT CO
80501-3128
US

V. Phone/Fax

Practice location:
  • Phone: 303-776-1234
  • Fax: 720-494-3107
Mailing address:
  • Phone: 303-776-1234
  • Fax: 720-494-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDR.0038013
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: