Provider Demographics
NPI:1356663587
Name:KELLER, MARY LOUISE (PAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:KELLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 WESTCHESTER DR
Mailing Address - Street 2:STE. 850
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7008
Mailing Address - Country:US
Mailing Address - Phone:336-802-2400
Mailing Address - Fax:336-802-2534
Practice Address - Street 1:4000 S SWAIM STREET EXT
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28642-9418
Practice Address - Country:US
Practice Address - Phone:336-835-6300
Practice Address - Fax:336-835-4761
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant