Healthcare Provider Details

I. General information

NPI: 1609406925
Provider Name (Legal Business Name): KATHERINE ELIZABETH KEKLAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2020
Last Update Date: 01/26/2020
Certification Date: 01/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TERRACE
GLENDALE CA
91206
US

IV. Provider business mailing address

750 E THIRD ST APT E11
POMONA CA
91766-2078
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-8000
  • Fax:
Mailing address:
  • Phone: 614-209-9013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number782159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: