Provider Demographics
NPI:1750406658
Name:KEOUGH, TAMMY E (FNP)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:E
Last Name:KEOUGH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:TAMMY
Other - Middle Name:E
Other - Last Name:CHARLTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:103 HALLS CV
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-6620
Mailing Address - Country:US
Mailing Address - Phone:662-562-9003
Mailing Address - Fax:662-562-4007
Practice Address - Street 1:103 HALLS CV
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-6620
Practice Address - Country:US
Practice Address - Phone:662-562-9003
Practice Address - Fax:662-562-4007
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12400363L00000X
MS902068363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08735004Medicaid
TN3341018Medicare PIN