Basic Information
| Provider Information | |||||||||
| NPI: | 1548686272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEATON | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEATON | ||||||||
| OtherFirstName: | SHELLEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068352235 | ||||||||
| FaxNumber: | 7068351706 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 DEEP SOUTH FARM RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BLAIRSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305122218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068352235 | ||||||||
| FaxNumber: | 7068351706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2014 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN107500 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 003144263A,B,D | 05 | GA | MEDICAID |