1508868126 NPI number — BRITTANY L. KELLER CRNA

Table of content: SHAYNA WILSON (NPI 1124753371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508868126 NPI number — BRITTANY L. KELLER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER
Provider First Name:
BRITTANY
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANDENBERG
Provider Other First Name:
BRITTANY
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508868126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 660257
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35266-0257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-979-5882
Provider Business Mailing Address Fax Number:
205-979-1248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3283 MALCOLM DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36116-8816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-356-9970
Provider Business Practice Location Address Fax Number:
334-356-9873
Provider Enumeration Date:
08/12/2005

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: 367500000X , with the licence number:  ARNP9226034 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 1-107535 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 306926500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59178101 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: G3673 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 009994005 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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