Healthcare Provider Details

I. General information

NPI: 1922000280
Provider Name (Legal Business Name): MADELYN M KECK A.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 N INDEPENDENCE STREET SUITE 700
ENID OK
73701-4046
US

IV. Provider business mailing address

PO BOX 844737 ATTN: IPM CREDENTIALING
DALLAS TX
75284-4737
US

V. Phone/Fax

Practice location:
  • Phone: 580-249-3066
  • Fax: 580-234-5385
Mailing address:
  • Phone: 903-416-1726
  • Fax: 903-416-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR0039619
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: