Provider Demographics
NPI:1649642406
Name:KEATHLEY, KATHRYN MOORE (APRN)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MOORE
Last Name:KEATHLEY
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-757-0434
Mailing Address - Fax:859-441-0906
Practice Address - Street 1:1640 FLOSSIE DR
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:IN
Practice Address - Zip Code:47025-8424
Practice Address - Country:US
Practice Address - Phone:812-496-3290
Practice Address - Fax:812-537-0400
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009737363LF0000X, 363L00000X
IN71007956A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100379650Medicaid
KYK196331Medicare PIN