Provider Demographics
NPI:1083789531
Name:KELLER, LEEANN RENEE (NP)
Entity Type:Individual
Prefix:MS
First Name:LEEANN
Middle Name:RENEE
Last Name:KELLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LEEANN
Other - Middle Name:RENEE
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1925 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:303-776-1234
Mailing Address - Fax:720-494-3107
Practice Address - Street 1:1925 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-776-1234
Practice Address - Fax:720-494-3107
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1626009163W00000X
COAPN.0991131-NP363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01479744OtherRR MEDICARE
CO98776851Medicaid
CO414000YPYSMedicare PIN