Provider Demographics
NPI:1023534724
Name:KELLER, KATELYN ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:ELIZABETH
Other - Last Name:LIPPERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-2000
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224
Practice Address - Country:US
Practice Address - Phone:904-953-2285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059176363AS0400X
FLPA9111238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical