Provider Demographics
NPI:1417232059
Name:KELLER, LACEE A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LACEE
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LACEE
Other - Middle Name:A
Other - Last Name:MOADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 E SCHAUMBURG RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-3548
Mailing Address - Country:US
Mailing Address - Phone:847-252-6090
Mailing Address - Fax:
Practice Address - Street 1:25 E SCHAUMBURG RD STE 101
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-3548
Practice Address - Country:US
Practice Address - Phone:847-252-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1417232059Medicaid