Provider Demographics
NPI:1316214240
Name:KELLER, NICOLE CHRISTINE (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:KELLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4789 ROUTE 71
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7415
Mailing Address - Country:US
Mailing Address - Phone:630-898-5969
Mailing Address - Fax:630-898-5837
Practice Address - Street 1:4789 ROUTE 71
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7415
Practice Address - Country:US
Practice Address - Phone:630-898-5969
Practice Address - Fax:630-898-5837
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129833208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics