1073678033 NPI number — MARY JEAN KELLER RN, NP

Table of content: BRETT HARROLD P.T.A. (NPI 1437275658)

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".




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