Provider Demographics
NPI:1447861778
Name:KEENEY, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
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 1:614 S BLAINE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3794
Mailing Address - Country:US
Mailing Address - Phone:208-596-8284
Mailing Address - Fax:
Practice Address - Street 1:1014 BURRELL AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5472
Practice Address - Country:US
Practice Address - Phone:208-743-4558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID086101186133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered