Provider Demographics
NPI:1811168941
Name:KIDD, KEITH L (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:L
Last Name:KIDD
Suffix:
Gender:M
Credentials:FNP-BC
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 15
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:TN
Mailing Address - Zip Code:37310-0015
Mailing Address - Country:US
Mailing Address - Phone:423-665-3666
Mailing Address - Fax:423-584-6747
Practice Address - Street 1:9026 HIWASSEE ST NE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:TN
Practice Address - Zip Code:37310-5305
Practice Address - Country:US
Practice Address - Phone:423-665-3666
Practice Address - Fax:423-584-6747
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007277Medicaid
TN02684136OtherAMERIGROUP
3476201OtherCIGNA