Healthcare Provider Details

I. General information

NPI: 1770968786
Provider Name (Legal Business Name): PANDA KEENER N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3090 SUGAR VALLEY RD
SUGAR VALLEY GA
30746
US

IV. Provider business mailing address

CIGNA ONSITE HEALTH LLC 25500 N NORTERRA DR
PHOENIX AZ
85085
US

V. Phone/Fax

Practice location:
  • Phone: 706-624-4661
  • Fax: 706-624-4698
Mailing address:
  • Phone: 623-277-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN222731
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: