1255598058 NPI number — KEATREDGE RE'TONDA LIGHTFOOT ARNP

Table of content: KEATREDGE RE'TONDA LIGHTFOOT ARNP (NPI 1255598058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255598058 NPI number — KEATREDGE RE'TONDA LIGHTFOOT ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIGHTFOOT
Provider First Name:
KEATREDGE
Provider Middle Name:
RE'TONDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRAZIER
Provider Other First Name:
KEATREDGE
Provider Other Middle Name:
RE'TONDA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255598058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 SHARONWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRAWFORDVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32327-0342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-421-2101
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8002 GUNN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33626-1603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-886-7673
Provider Business Practice Location Address Fax Number:
813-792-7895
Provider Enumeration Date:
05/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  ARNP9181344 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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