Healthcare Provider Details

I. General information

NPI: 1376189308
Provider Name (Legal Business Name): KEITH ALLEN KIRBOW APRN, FNP-C, PMHNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 6TH ST
LONGVIEW TX
75601-5567
US

IV. Provider business mailing address

887 HACK BERRY RD
GILMER TX
75644-8432
US

V. Phone/Fax

Practice location:
  • Phone: 903-921-1813
  • Fax:
Mailing address:
  • Phone: 903-806-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP144151
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP144151
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: