Healthcare Provider Details

I. General information

NPI: 1528058732
Provider Name (Legal Business Name): KEITH ALEXANDER CLEMENT NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 MERRICK RD
LYNBROOK NY
11563-2460
US

IV. Provider business mailing address

94 CUBA HILL RD
GREENLAWN NY
11740-2720
US

V. Phone/Fax

Practice location:
  • Phone: 516-887-0890
  • Fax:
Mailing address:
  • Phone: 631-754-4472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF302992
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: