Provider Demographics
NPI:1104430305
Name:KEOWN, NIKKI PAGE
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:PAGE
Last Name:KEOWN
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 1:12136 LUFTBURROW LN
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34669-5005
Mailing Address - Country:US
Mailing Address - Phone:704-616-5790
Mailing Address - Fax:
Practice Address - Street 1:12136 LUFTBURROW LN
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34669-5005
Practice Address - Country:US
Practice Address - Phone:704-616-5790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer