Provider Demographics
NPI:1902556426
Name:KEENE, MIKAELA
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:KEENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7448 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-6069
Mailing Address - Country:US
Mailing Address - Phone:623-979-0558
Mailing Address - Fax:
Practice Address - Street 1:7448 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-6069
Practice Address - Country:US
Practice Address - Phone:623-979-0558
Practice Address - Fax:623-979-9281
Is Sole Proprietor?:No
Enumeration Date:2022-03-27
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZT071140183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician