Provider Demographics
NPI:1568476224
Name:KELLER, KRISTINA MARIE (FNP)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754
Mailing Address - Country:US
Mailing Address - Phone:541-447-0707
Mailing Address - Fax:541-447-0708
Practice Address - Street 1:980 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754
Practice Address - Country:US
Practice Address - Phone:541-447-0707
Practice Address - Fax:541-447-0708
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH682402OtherPACIFIC SOUTH HEALTH PLAN
ORH682421OtherPACIFIC SOUTH HEALTH PLAN
OR182960Medicaid
OR131000Medicare ID - Type Unspecified
P88233Medicare UPIN