Provider Demographics
NPI:1851857833
Name:GRIFFIE, KEON IDRIS (FNP)
Entity Type:Individual
Prefix:MR
First Name:KEON
Middle Name:IDRIS
Last Name:GRIFFIE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 TIMBERLANE ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-9521
Mailing Address - Country:US
Mailing Address - Phone:903-691-3694
Mailing Address - Fax:
Practice Address - Street 1:712 S CASCADE ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2913
Practice Address - Country:US
Practice Address - Phone:903-691-3694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136967363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily