Provider Demographics
NPI:1225681067
Name:KEEBLER, MALLORY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ELIZABETH
Last Name:KEEBLER
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 1:4612 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6110
Mailing Address - Country:US
Mailing Address - Phone:859-801-9231
Mailing Address - Fax:
Practice Address - Street 1:3101 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3014
Practice Address - Country:US
Practice Address - Phone:513-357-7289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF09200163363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily