Provider Demographics
NPI:1689262560
Name:KELLER, TIA (LPN)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 WAYWOOD STREET
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791
Mailing Address - Country:US
Mailing Address - Phone:225-372-5107
Mailing Address - Fax:
Practice Address - Street 1:2415 WAYWOOD STREET
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791
Practice Address - Country:US
Practice Address - Phone:225-372-5107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20130840164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse