Provider Demographics
NPI:1407869530
Name:KEITH, FELICIA DENISE (CRNA)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:DENISE
Last Name:KEITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2563
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-2563
Mailing Address - Country:US
Mailing Address - Phone:706-271-0100
Mailing Address - Fax:706-270-0487
Practice Address - Street 1:1200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2529
Practice Address - Country:US
Practice Address - Phone:706-259-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN1178178163W00000X
GARN135293163W00000X
TNAPN12242367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3638020Medicaid
TN4156148OtherBLUE CROSS BLUE SHIELD TN
GA457182117AMedicaid
GAN421141OtherWELLCARE (GA MEDICAID)
NC8052757Medicaid
TNP00460064OtherRAILROAD MEDICARE
AL009911719Medicaid
GAN421141OtherWELLCARE (GA MEDICAID)
TN3638020Medicare PIN