Provider Demographics
NPI:1194384248
Name:KELLER, MACKENZIE (ARNP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:FULLERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-7900
Mailing Address - Fax:515-643-7901
Practice Address - Street 1:411 LAUREL ST STE A120
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3027
Practice Address - Country:US
Practice Address - Phone:515-643-7900
Practice Address - Fax:515-643-7901
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH154519363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner