Healthcare Provider Details

I. General information

NPI: 1023088150
Provider Name (Legal Business Name): MARTHA JANE KEENER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 E CHURCHVILLE RD CVS/MINUTECLINIC
BEL AIR MD
21015
US

IV. Provider business mailing address

43 BOXTHORN RD
ABINGDON MD
21009-1716
US

V. Phone/Fax

Practice location:
  • Phone: 410-828-0708
  • Fax:
Mailing address:
  • Phone: 410-569-8075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR162682
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR162682
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: