1073678033 NPI number — MARY JEAN KELLER RN, NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073678033 NPI number — MARY JEAN KELLER RN, NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
MARY
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073678033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4046
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65808-4046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-269-5712
Provider Business Mailing Address Fax Number:
417-269-7567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MARY KELLER
Provider Second Line Business Practice Location Address:
785 ELKRIDGE LANDING SUITE #300
Provider Business Practice Location Address City Name:
LINTHICUM HEIGHTS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-379-7253
Provider Business Practice Location Address Fax Number:
844-464-0583
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  091099 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00635675 . This is a "TRAVELERS RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 171101758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1073678033 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431560263 . This is a "TRICARE WEST" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com