Provider Demographics
NPI:1376013037
Name:KELLER, KAILI (ATC)
Entity Type:Individual
Prefix:MS
First Name:KAILI
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 E 61ST ST APT 6HS
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-0382
Mailing Address - Country:US
Mailing Address - Phone:408-612-5899
Mailing Address - Fax:
Practice Address - Street 1:252 E 61ST ST APT 6HS
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-0382
Practice Address - Country:US
Practice Address - Phone:408-612-5899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0024742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer