Provider Demographics
NPI:1306393939
Name:KELLER, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
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 1:700 CORPORATE BOULAVERD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550
Mailing Address - Country:US
Mailing Address - Phone:845-337-9007
Mailing Address - Fax:
Practice Address - Street 1:700 CORPORATE BOULAVERD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550
Practice Address - Country:US
Practice Address - Phone:845-337-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272398163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse