Provider Demographics
NPI:1659544658
Name:KELLER, SALLY D (ARNP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:D
Last Name:KELLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-1960
Mailing Address - Country:US
Mailing Address - Phone:904-964-7732
Mailing Address - Fax:904-964-3024
Practice Address - Street 1:1801 N TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-1960
Practice Address - Country:US
Practice Address - Phone:904-964-7732
Practice Address - Fax:904-964-3024
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 511742363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health