Healthcare Provider Details

I. General information

NPI: 1396733739
Provider Name (Legal Business Name): MARY JEANNE KEITH RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CARLSON PARKWAY CP340
MINNETONKA MN
55305-5387
US

IV. Provider business mailing address

1718 W 66TH ST
RICHFIELD MN
55423-2138
US

V. Phone/Fax

Practice location:
  • Phone: 952-992-3604
  • Fax: 612-866-0459
Mailing address:
  • Phone: 612-861-1080
  • Fax: 612-866-0459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number136908-23
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: