Provider Demographics
NPI:1235862145
Name:KELLER, LATASHA NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:NICOLE
Last Name:KELLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 WILLOW BAY DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2842
Mailing Address - Country:US
Mailing Address - Phone:803-290-6944
Mailing Address - Fax:
Practice Address - Street 1:148 WILLOW BAY DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2842
Practice Address - Country:US
Practice Address - Phone:803-290-6944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC249610163W00000X
SC27024363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse