Provider Demographics
NPI:1376563007
Name:KELLER, LAURA (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2460
Mailing Address - Street 2:560 MAIN STREET
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093-2460
Mailing Address - Country:US
Mailing Address - Phone:530-623-3735
Mailing Address - Fax:530-623-1196
Practice Address - Street 1:560 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093
Practice Address - Country:US
Practice Address - Phone:530-623-3735
Practice Address - Fax:530-623-1196
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8729363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN476117Medicaid