Provider Demographics
NPI:1013211010
Name:KELLER, MALLORY DIANE
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:DIANE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:DIANE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7501 BELINDER AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-3659
Mailing Address - Country:US
Mailing Address - Phone:913-787-3275
Mailing Address - Fax:
Practice Address - Street 1:7501 BELINDER AVE
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-3659
Practice Address - Country:US
Practice Address - Phone:913-787-3275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator