Healthcare Provider Details

I. General information

NPI: 1255496881
Provider Name (Legal Business Name): LEWIS WESLEY KEEN JR. MSN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 J K AVENT DR
GRENADA MS
38901-5230
US

IV. Provider business mailing address

867 HAILE RD
GORE SPRINGS MS
38929-9549
US

V. Phone/Fax

Practice location:
  • Phone: 662-227-7375
  • Fax:
Mailing address:
  • Phone: 662-226-9889
  • Fax: 662-229-9889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR640557
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: