Provider Demographics
NPI:1154664670
Name:KEOGH, RYAN JAMES (RN)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:JAMES
Last Name:KEOGH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HARTWELL AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-3100
Mailing Address - Country:US
Mailing Address - Phone:781-861-0890
Mailing Address - Fax:
Practice Address - Street 1:125 HARTWELL AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-3100
Practice Address - Country:US
Practice Address - Phone:781-861-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2023-05-24
Deactivation Date:2021-09-20
Deactivation Code:
Reactivation Date:2021-10-20
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103K00000X
MARN2331463363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst