Provider Demographics
NPI:1801191580
Name:KELLER, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:5724 CALLISTER AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-1809
Mailing Address - Country:US
Mailing Address - Phone:916-716-7547
Mailing Address - Fax:
Practice Address - Street 1:11960 HERITAGE OAK PL
Practice Address - Street 2:STE 15
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2401
Practice Address - Country:US
Practice Address - Phone:530-885-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW3424390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program