=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609413251
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEARA LEIGH EAGAN APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2019
-----------------------------------------------------
Last Update Date | 05/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 VILLAGE GREEN DR STE B
-----------------------------------------------------
City | SWEDESBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08085-3253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-467-7360
-----------------------------------------------------
Fax | 856-467-5959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1020 LAUREL OAK RD STE 102
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-783-1777
-----------------------------------------------------
Fax | 856-783-8519
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00984200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------