Provider Demographics
NPI:1164512141
Name:KELLER, KRISTY A (MD)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6353 CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4100
Mailing Address - Country:US
Mailing Address - Phone:561-486-8439
Mailing Address - Fax:757-594-2195
Practice Address - Street 1:500 SENTARA CIR STE 105
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5754
Practice Address - Country:US
Practice Address - Phone:757-253-5653
Practice Address - Fax:757-378-2776
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239578207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1164512141Medicaid
VA1164512141Medicaid
I52126Medicare UPIN