Provider Demographics
NPI:1902438849
Name:KEEN, TONYA JEAN
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:JEAN
Last Name:KEEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TONYA
Other - Middle Name:JEAN
Other - Last Name:KEEN SHELTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1182
Mailing Address - Street 2:
Mailing Address - City:RAVEN
Mailing Address - State:VA
Mailing Address - Zip Code:24639-1182
Mailing Address - Country:US
Mailing Address - Phone:276-971-4567
Mailing Address - Fax:
Practice Address - Street 1:2300 PAVILION DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4622
Practice Address - Country:US
Practice Address - Phone:423-765-9655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA0000001446224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNOTA0000001446OtherOCCUPATIONAL THERAPY ASSISTANT