Provider Demographics
NPI:1518079979
Name:KELLER, MARILOU (CNS)
Entity Type:Individual
Prefix:
First Name:MARILOU
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37197 BUNCHBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-3259
Mailing Address - Country:US
Mailing Address - Phone:951-766-6460
Mailing Address - Fax:
Practice Address - Street 1:301 N SAN JACINTO ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3119
Practice Address - Country:US
Practice Address - Phone:951-766-6460
Practice Address - Fax:951-766-6459
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACNS2201364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1639109457OtherNPI
CA05D1062719OtherCLIA NUMBER
CA1639109457OtherNPI
CAZZZ05355ZMedicare PIN