Provider Demographics
NPI:1811398233
Name:KEITH, LEAH (NP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1267 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2114
Mailing Address - Country:US
Mailing Address - Phone:770-716-0051
Mailing Address - Fax:770-716-0087
Practice Address - Street 1:1267 HIGHWAY 54 W
Practice Address - Street 2:SUITE 2200
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2114
Practice Address - Country:US
Practice Address - Phone:770-716-0051
Practice Address - Fax:770-716-0087
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106717363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health