1508868126 NPI number — BRITTANY L. KELLER CRNA

Table of content: BRITTANY L. KELLER CRNA (NPI 1508868126)

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".




Copyright © 2007-2024 www.npivalidator.com