Basic Information
| Provider Information | |||||||||
| NPI: | 1063435600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEANE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 SAN MARCO BLVD | ||||||||
| Address2: | SUITE 701 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463465 | ||||||||
| FaxNumber: | 9048586490 | ||||||||
| Practice Location | |||||||||
| Address1: | 14540 OLD SAINT AUGUSTINE RD | ||||||||
| Address2: | SUITE 2201 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322587418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048801260 | ||||||||
| FaxNumber: | 9048801210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AL2050 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | PA9106645 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.