Provider Demographics
NPI:1659895746
Name:KEITH, KAELYN MICHELE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KAELYN
Middle Name:MICHELE
Last Name:KEITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 SINGLETON WAYNESBURG RD
Mailing Address - Street 2:
Mailing Address - City:EUBANK
Mailing Address - State:KY
Mailing Address - Zip Code:42567-8593
Mailing Address - Country:US
Mailing Address - Phone:606-271-7631
Mailing Address - Fax:
Practice Address - Street 1:9510 ORMSBY STATION RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4082
Practice Address - Country:US
Practice Address - Phone:502-327-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
14075517OtherCAQH
KY7100505230Medicaid