Healthcare Provider Details

I. General information

NPI: 1023666070
Provider Name (Legal Business Name): BROOKE KEENAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19455 DEERFIELD AVE STE 201
LANSDOWNE VA
20176-8102
US

IV. Provider business mailing address

ONE GI CREDENTIALING DEPARTMENT PO BOX 381468
GERMANTOWN TN
38183-1468
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-3670
  • Fax: 877-325-2018
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN-0010891
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD02351
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number898646
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: