=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265850796
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA MICHELLE KEITH FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2014
-----------------------------------------------------
Last Update Date | 06/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 STUART RD NE STE 1
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37312-4995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-303-7966
-----------------------------------------------------
Fax | 423-458-4338
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 STUART RD NE STE 1
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37312-4995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-303-7966
-----------------------------------------------------
Fax | 423-458-4338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 18531
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------