Healthcare Provider Details

I. General information

NPI: 1164775649
Provider Name (Legal Business Name): GINA ANGEL KEATLEY MBA, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2012
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 BROADWAY SUITE 302
NEW YORK NY
10012-3396
US

IV. Provider business mailing address

173 HOPKINS ST APT 3L
BROOKLYN NY
11206-5021
US

V. Phone/Fax

Practice location:
  • Phone: 800-571-8276
  • Fax: 888-974-0289
Mailing address:
  • Phone: 800-571-8276
  • Fax: 888-974-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number007594
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number007594
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number007594
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number007594
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: