Provider Demographics
NPI:1689754780
Name:KELLER, BRIAN J (RN)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:KELLER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 E DIVIDE AVE
Mailing Address - Street 2:RJB ARMORY
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-7905
Mailing Address - Country:US
Mailing Address - Phone:701-333-3014
Mailing Address - Fax:701-333-3016
Practice Address - Street 1:4200 E DIVIDE AVE
Practice Address - Street 2:RJB ARMORY
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-7905
Practice Address - Country:US
Practice Address - Phone:701-333-3014
Practice Address - Fax:701-333-3016
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR26186163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse