Provider Demographics
NPI:1598736514
Name:KELLER, SUSAN (APN,)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:APN,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 MEMORIAL DRIVE CREDENTIALING DEPARTMENT
Mailing Address - Street 2:MEMORIAL HOSPITAL MEDICAL AFFAIRS
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-257-4644
Mailing Address - Fax:
Practice Address - Street 1:130 LINCOLN PLACE CT
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5884
Practice Address - Country:US
Practice Address - Phone:618-257-2029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001731363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILIL3521009Medicare PIN
IL208438Medicare ID - Type Unspecified