MEDICARE: MR. KEITH L KIDD FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	13254	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	02684136	OTHER	TN	AMERIGROUP
3	3476201	OTHER		CIGNA

General Provider Information

NPI Number	:	1811168941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH L KIDD FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 15
Second Line	:
City	:	CHARLESTON
State	:	TN
Zip	:	37310-0015
Country	:	US
Telephone Number	:	423-665-3666
Fax Number	:	423-584-6747

Provider Business Practice Location Address
First Line	:	9026 HIWASSEE ST NE
Second Line	:
City	:	CHARLESTON
State	:	TN
Zip	:	37310-5305
Country	:	US
Telephone Number	:	423-665-3666
Fax Number	:	423-584-6747

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	10/29/2021

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