Provider Demographics
NPI:1265249916
Name:KEAGLE, TANIKA JANAE (AGPCNP)
Entity type:Individual
Prefix:
First Name:TANIKA
Middle Name:JANAE
Last Name:KEAGLE
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 9TH ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1544
Mailing Address - Country:US
Mailing Address - Phone:757-822-9965
Mailing Address - Fax:
Practice Address - Street 1:568 9TH ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1544
Practice Address - Country:US
Practice Address - Phone:757-822-9965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024191131363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology