Provider Demographics
NPI:1164897625
Name:COGAN, KEIGHLY GRACE (RN)
Entity Type:Individual
Prefix:MS
First Name:KEIGHLY
Middle Name:GRACE
Last Name:COGAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:KEIGHLY
Other - Middle Name:GRACE
Other - Last Name:KILSGAARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:261 E WILLOW ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2637
Mailing Address - Country:US
Mailing Address - Phone:562-735-6131
Mailing Address - Fax:562-290-0251
Practice Address - Street 1:261 E WILLOW ST
Practice Address - Street 2:SUITE C
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2637
Practice Address - Country:US
Practice Address - Phone:562-735-6131
Practice Address - Fax:562-290-0251
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034140163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0150193OtherMEDI-CAL