Basic Information
| Provider Information | |||||||||
| NPI: | 1184013534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITH | ||||||||
| FirstName: | MARA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AGNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LINDBERG | ||||||||
| OtherFirstName: | MARA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8401 MEDICAL PLAZA DR | ||||||||
| Address2: | STE 365 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282628797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049440975 | ||||||||
| FaxNumber: | 7049433699 | ||||||||
| Practice Location | |||||||||
| Address1: | 8401 MEDICAL PLAZA DR | ||||||||
| Address2: | STE 365 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282628797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049440975 | ||||||||
| FaxNumber: | 7049433699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2015 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5007439 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.