Healthcare Provider Details

I. General information

NPI: 1023652948
Provider Name (Legal Business Name): ROBERT DONALD KEEN NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 ROLLING RD
VALDOSTA GA
31602-1218
US

IV. Provider business mailing address

50 S B B KING BLVD STE 100
MEMPHIS TN
38103-2626
US

V. Phone/Fax

Practice location:
  • Phone: 229-560-4575
  • Fax:
Mailing address:
  • Phone: 901-422-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN105604
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: