Provider Demographics
NPI:1093309163
Name:KELLER, CAROLYN A
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 IVAN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26181-9678
Mailing Address - Country:US
Mailing Address - Phone:304-863-3695
Mailing Address - Fax:
Practice Address - Street 1:107 IVAN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:WV
Practice Address - Zip Code:26181-9678
Practice Address - Country:US
Practice Address - Phone:304-863-3695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker