Provider Demographics
NPI:1609406925
Name:KEKLAK, KATHERINE ELIZABETH (RN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:KEKLAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E THIRD ST APT E11
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2078
Mailing Address - Country:US
Mailing Address - Phone:614-209-9013
Mailing Address - Fax:
Practice Address - Street 1:1509 WILSON TERRACE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA782159163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health