Provider Demographics
NPI:1073678033
Name:KELLER, MARY JEAN (RN, NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:KELLER
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3525 S NATIONAL AVE STE 207
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7315
Practice Address - Country:US
Practice Address - Phone:417-269-9220
Practice Address - Fax:417-269-9229
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO091099363LF0000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00635675OtherTRAVELERS RR MEDICARE
MO1073678033Medicaid
AR171101758Medicaid
MO431560263OtherTRICARE WEST
MO132680019Medicare PIN
MO1073678033Medicaid