Healthcare Provider Details

I. General information

NPI: 1265249916
Provider Name (Legal Business Name): TANIKA JANAE KEAGLE AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 FAIRFAX AVE
NORFOLK VA
23507-2007
US

IV. Provider business mailing address

721 FAIRFAX AVE FL 4
NORFOLK VA
23507-2007
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-7040
  • Fax: 757-446-7049
Mailing address:
  • Phone: 757-446-7040
  • Fax: 757-446-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024191131
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: