Provider Demographics
NPI:1619646460
Name:KELLER, STEPHANIE A (HIS)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:A
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HIS
Mailing Address - Street 1:615 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3704
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:618-215-2169
Practice Address - Street 1:9997 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-1927
Practice Address - Country:US
Practice Address - Phone:314-821-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20021033554237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist