Provider Demographics
NPI:1497762256
Name:KEYS, GRETA LOUISE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:GRETA
Middle Name:LOUISE
Last Name:KEYS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:GRETA
Other - Middle Name:L
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:332 E MONTICELLO ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3430
Mailing Address - Country:US
Mailing Address - Phone:601-833-3500
Mailing Address - Fax:601-292-6384
Practice Address - Street 1:332 E MONTICELLO ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3430
Practice Address - Country:US
Practice Address - Phone:601-833-3500
Practice Address - Fax:601-292-6384
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR843927363LF0000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04187246Medicaid
MS2014619OtherCIGNA
MSP00823061OtherRAILROAD MEDICARE
MS302I505295Medicare PIN
MSPTAN 302I500382Medicare PIN