1902438849 NPI number — TONYA JEAN KEEN

Table of content: TONYA JEAN KEEN (NPI 1902438849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902438849 NPI number — TONYA JEAN KEEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEEN
Provider First Name:
TONYA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEEN SHELTON
Provider Other First Name:
TONYA
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1902438849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1182
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAVEN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24639-1182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-971-4567
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 PAVILION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-765-9655
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  OTA0000001446 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OTA0000001446 . This is a "OCCUPATIONAL THERAPY ASSISTANT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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