Healthcare Provider Details

I. General information

NPI: 1306884374
Provider Name (Legal Business Name): CORETTA D. KEITH DNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 18TH ST E
TIFTON GA
31794-3648
US

IV. Provider business mailing address

116 BEOWULF LN
LEESBURG GA
31763-5831
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-7120
  • Fax:
Mailing address:
  • Phone: 404-710-6646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN124581
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4450
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: