Basic Information
| Provider Information | |||||||||
| NPI: | 1043668619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEOUGH | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CERVI | ||||||||
| OtherFirstName: | BRITTANY | ||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 318 ARLINGTON DR | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483072806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343557332 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 GENESYS PKWY | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484398065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106065000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2016 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704285694 | MI | N | Nursing Service Providers | Registered Nurse | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | 4704285694 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.