Provider Demographics
NPI:1407249121
Name:KELLER, SAMANTHA (CDM)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 E BROADVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8302
Mailing Address - Country:US
Mailing Address - Phone:907-373-3420
Mailing Address - Fax:
Practice Address - Street 1:2650 E BROADVIEW AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8302
Practice Address - Country:US
Practice Address - Phone:907-373-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK76175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay