Provider Demographics
NPI:1124585880
Name:KEEN, KRISTA LAUREN (NP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LAUREN
Last Name:KEEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:SHUGART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3448 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1867
Mailing Address - Country:US
Mailing Address - Phone:478-405-0045
Mailing Address - Fax:478-405-0054
Practice Address - Street 1:3448 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1867
Practice Address - Country:US
Practice Address - Phone:478-405-0045
Practice Address - Fax:478-405-0054
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN209195363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily