Provider Demographics
NPI:1871070763
Name:KEITH, BREANNA (NP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3157
Mailing Address - Fax:812-242-3861
Practice Address - Street 1:1530 N 7TH ST STE 101
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1058
Practice Address - Country:US
Practice Address - Phone:812-238-7878
Practice Address - Fax:812-238-7808
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008152A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner