Provider Demographics
NPI:1629627864
Name:KELLER, ELIZABETH GREER
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GREER
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 1:9344 NATIONAL BLVD APT 8
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-2925
Mailing Address - Country:US
Mailing Address - Phone:717-679-1678
Mailing Address - Fax:
Practice Address - Street 1:2021 SANTA MONICA BLVD STE 440E
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2154
Practice Address - Country:US
Practice Address - Phone:310-453-1386
Practice Address - Fax:310-453-4786
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant