Provider Demographics
NPI:1760529283
Name:KELLER, MAGGIE RUTH
Entity Type:Individual
Prefix:MRS
First Name:MAGGIE
Middle Name:RUTH
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 1:220 SHELBI PL
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-7417
Mailing Address - Country:US
Mailing Address - Phone:662-234-6626
Mailing Address - Fax:
Practice Address - Street 1:220 SHELBI PL
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-7417
Practice Address - Country:US
Practice Address - Phone:662-234-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP149861164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770203Medicaid