Basic Information
| Provider Information | |||||||||
| NPI: | 1043551807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEANE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146479444 | ||||||||
| FaxNumber: | 3146477317 | ||||||||
| Practice Location | |||||||||
| Address1: | 1031 BELLEVUE AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146479444 | ||||||||
| FaxNumber: | 3146477317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2013 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2006021094 | MO | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 2013000128 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.