Provider Demographics
NPI:1902083488
Name:KEENEY, NICOLE TERESE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:TERESE
Last Name:KEENEY
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 1:10326 GRENDEL CT
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-5833
Mailing Address - Country:US
Mailing Address - Phone:804-550-7839
Mailing Address - Fax:
Practice Address - Street 1:WALTER REED ARMY MEDICAL CENTER
Practice Address - Street 2:6900 GEORGIA AVE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20307-0001
Practice Address - Country:US
Practice Address - Phone:202-782-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-27
Last Update Date:2008-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1084133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered