Provider Demographics
NPI:1326638560
Name:KELLER, FREDERIQUE (LAC)
Entity Type:Individual
Prefix:MS
First Name:FREDERIQUE
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2626
Mailing Address - Country:US
Mailing Address - Phone:631-351-3521
Mailing Address - Fax:
Practice Address - Street 1:408 FORT SALONGA RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3075
Practice Address - Country:US
Practice Address - Phone:631-351-3521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY990171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty