Provider Demographics
NPI:1578932620
Name:KEITHLEY, KATRINA MARGARET (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:MARGARET
Last Name:KEITHLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9669 KENTON AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1227
Mailing Address - Country:US
Mailing Address - Phone:847-679-6333
Mailing Address - Fax:
Practice Address - Street 1:9669 KENTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-679-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006211363A00000X
MI5601007532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant