Provider Demographics
NPI:1962624767
Name:KEESHEN, GAYLE
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:KEESHEN
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 1:4 LEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1897
Mailing Address - Country:US
Mailing Address - Phone:207-641-5511
Mailing Address - Fax:
Practice Address - Street 1:1011 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3304
Practice Address - Country:US
Practice Address - Phone:207-781-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1641174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEOT1641Medicaid