Provider Demographics
NPI:1013067610
Name:KEOGH, KATHLEEN ANNETTE (RN, CNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNETTE
Last Name:KEOGH
Suffix:
Gender:F
Credentials:RN, CNP
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:16183 TAHINKA PL NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1055 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1065
Practice Address - Country:US
Practice Address - Phone:651-635-9173
Practice Address - Fax:612-262-7989
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR117190-9363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1027328-00Medicaid
MN1027328-00Medicaid
MN500002861Medicare ID - Type Unspecified