Provider Demographics
NPI:1578162921
Name:MCGOUGH, KEELY (DNP)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-1818
Mailing Address - Country:US
Mailing Address - Phone:405-632-6688
Mailing Address - Fax:
Practice Address - Street 1:4000 W RENO AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6632
Practice Address - Country:US
Practice Address - Phone:405-632-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-17
Last Update Date:2021-09-30
Deactivation Date:2020-11-01
Deactivation Code:
Reactivation Date:2020-11-18
Provider Licenses
StateLicense IDTaxonomies
OKR0117106363LF0000X
CAG431360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1801808357Medicaid
CA770172743Medicaid
OK22927742OtherNCSBN
OKR0117106OtherAPRN-CNP LICENSE