Healthcare Provider Details

I. General information

NPI: 1174570816
Provider Name (Legal Business Name): KATHERINE A KEELEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2649 WIGWAM PKWY SUITE 102
HENDERSON NV
89074-7310
US

IV. Provider business mailing address

2649 WIGWAM PKWY #102
HENDERSON NV
89074-7310
US

V. Phone/Fax

Practice location:
  • Phone: 702-263-9339
  • Fax:
Mailing address:
  • Phone: 702-263-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number152681
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: