Provider Demographics
NPI:1962413401
Name:KEANE, EILEEN F (PNP)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:F
Last Name:KEANE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3733
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:203-777-8506
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3733
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-8506
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006169163WP0200X
CT6169363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP9903OtherBCBS
MAY10141OtherBCBS-GROUP
MA1300709Medicaid
MA56780OtherFALLON SELECT
MAY10141Medicare ID - Type UnspecifiedPART B-GROUP
MA221804Medicare ID - Type UnspecifiedPART A-GROUP
MAY10141OtherBCBS-GROUP
MA1300709Medicaid
MAOTH000Medicare UPIN