Basic Information
| Provider Information | |||||||||
| NPI: | 1013067610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEOGH | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANNETTE | ||||||||
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| Credential: | RN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16183 TAHINKA PL NW | ||||||||
| Address2: | |||||||||
| City: | PRIOR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553721850 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 WESTGATE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516359173 | ||||||||
| FaxNumber: | 6122627989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 04/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | R117190-9 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 1027328-00 | 05 | MN | MEDICAID |