Provider Demographics
NPI:1114358587
Name:KEOUGH, KRISTEN (BSN, RN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KEOUGH
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-3063
Mailing Address - Country:US
Mailing Address - Phone:617-794-0471
Mailing Address - Fax:
Practice Address - Street 1:661 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-3063
Practice Address - Country:US
Practice Address - Phone:617-794-0471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2287394163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse