Provider Demographics
NPI:1609358829
Name:KELLER, CONNIE SUE
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:SUE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5038 SOUTHPOINTE PKWY
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-4540
Mailing Address - Country:US
Mailing Address - Phone:734-243-6943
Mailing Address - Fax:
Practice Address - Street 1:5038 SOUTHPOINTE PKWY
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-4540
Practice Address - Country:US
Practice Address - Phone:734-243-6943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704218073363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner