Provider Demographics
NPI:1225348824
Name:KEOGH, AMANDA K (ANP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:K
Last Name:KEOGH
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 NO SMITH AVE #100
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:651-241-5000
Mailing Address - Fax:651-241-7678
Practice Address - Street 1:255 NO SMITH AVE #100
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-241-5000
Practice Address - Fax:651-241-7678
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1754520363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health