Provider Demographics
NPI:1851677157
Name:KEOGH, KEVIN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KEOGH
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37083-1701
Mailing Address - Country:US
Mailing Address - Phone:615-666-2056
Mailing Address - Fax:
Practice Address - Street 1:209 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-1701
Practice Address - Country:US
Practice Address - Phone:615-666-2056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000016238363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP02067604OtherRAILROAD MEDICARE