Provider Demographics
NPI:1235676099
Name:PRIDDLE, KEITH (FNP-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PRIDDLE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 E COUNTY LINE RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1082
Mailing Address - Country:US
Mailing Address - Phone:317-789-9600
Mailing Address - Fax:317-789-0600
Practice Address - Street 1:747 E COUNTY LINE RD STE B
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1082
Practice Address - Country:US
Practice Address - Phone:317-789-9600
Practice Address - Fax:317-789-0600
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28205187A163W00000X
IN71007578A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse