Provider Demographics
NPI:1003991530
Name:KELLER, AUDREY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-9518
Mailing Address - Country:US
Mailing Address - Phone:231-745-3116
Mailing Address - Fax:231-745-3136
Practice Address - Street 1:525 4TH ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-9518
Practice Address - Country:US
Practice Address - Phone:231-745-3116
Practice Address - Fax:231-745-3136
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO2225207Q00000X
MI5601005193363A00000X
CA22536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine