Healthcare Provider Details

I. General information

NPI: 1689034514
Provider Name (Legal Business Name): AMANDA L KEITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4944 GREENSBORO RD
RIDGEWAY VA
24148-3390
US

IV. Provider business mailing address

4944 GREENSBORO RD
RIDGEWAY VA
24148-3390
US

V. Phone/Fax

Practice location:
  • Phone: 276-956-2233
  • Fax: 276-956-1629
Mailing address:
  • Phone: 276-956-2233
  • Fax: 276-956-1629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173325
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: