Healthcare Provider Details

I. General information

NPI: 1922290402
Provider Name (Legal Business Name): MICHELLE ANN KEANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9611 W BROWARD BLVD
PLANTATION FL
33324-2334
US

IV. Provider business mailing address

900 S PINE ISLAND RD STE 800
PLANTATION FL
33324-3923
US

V. Phone/Fax

Practice location:
  • Phone: 954-424-7000
  • Fax: 954-436-0449
Mailing address:
  • Phone: 954-431-8000
  • Fax: 954-436-0449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberME108902
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME108902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: