Provider Demographics
NPI:1306514708
Name:KEOUGH, SHELLY ANN (APRN-CNP, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:ANN
Last Name:KEOUGH
Suffix:
Gender:F
Credentials:APRN-CNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 ESPANA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-5416
Mailing Address - Country:US
Mailing Address - Phone:972-523-9044
Mailing Address - Fax:
Practice Address - Street 1:503 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-3235
Practice Address - Country:US
Practice Address - Phone:972-937-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1049146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1049146OtherAPRN LICENSE NUMBER