Healthcare Provider Details

I. General information

NPI: 1598484610
Provider Name (Legal Business Name): KEYANNA TANISHA GUIDRY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 N BENBOW RD
GREENSBORO NC
27411-0001
US

IV. Provider business mailing address

402 PEACH ORCHARD DR
GREENSBORO NC
27455-1500
US

V. Phone/Fax

Practice location:
  • Phone: 336-334-7880
  • Fax:
Mailing address:
  • Phone: 336-558-7873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07221243
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5016805
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: