Basic Information
| Provider Information | |||||||||
| NPI: | 1952351355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTHONY | ||||||||
| FirstName: | KEATA | ||||||||
| MiddleName: | LORRAINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383402231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319890001 | ||||||||
| FaxNumber: | 7319895151 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383404003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319890001 | ||||||||
| FaxNumber: | 7319895151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN#6159 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 621620777 | 01 | TN | TRICARE | OTHER | 4052228 | 01 | TN | BCBS | OTHER | 3908653 | 05 | TN | MEDICAID | MA0902886 | 01 | TN | DEA | OTHER |