Healthcare Provider Details

I. General information

NPI: 1861895955
Provider Name (Legal Business Name): JUDIANNE KEIGHTLY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 RIVERSIDE DR STE A206
SALISBURY MD
21801
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-5640
  • Fax:
Mailing address:
  • Phone: 410-546-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberSP013644
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAC002004
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAC002004
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: