Healthcare Provider Details

I. General information

NPI: 1982525275
Provider Name (Legal Business Name): MIKAYLA LEE KEENAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAYLEE KEENAN

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 LABORE RD
LITTLE CANADA MN
55117-1222
US

IV. Provider business mailing address

774 LABORE RD
LITTLE CANADA MN
55117-1222
US

V. Phone/Fax

Practice location:
  • Phone: 651-600-0846
  • Fax:
Mailing address:
  • Phone: 651-600-0846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: