Provider Demographics
NPI:1487112918
Name:KELLER, KELLY RENEE (SCHOOL NURSE)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:KELLER
Suffix:
Gender:F
Credentials:SCHOOL NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-2711
Mailing Address - Country:US
Mailing Address - Phone:618-993-2198
Mailing Address - Fax:
Practice Address - Street 1:411 S COURT ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-2711
Practice Address - Country:US
Practice Address - Phone:618-993-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041309727163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1902070642Medicaid