Provider Demographics
NPI:1821379397
Name:KELLER OSSIPOV, DONNA MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARIE
Last Name:KELLER OSSIPOV
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:DONNA
Other - Middle Name:MARIE
Other - Last Name:KELLER OSSIPOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:7058 W PEBBLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85757-8745
Mailing Address - Country:US
Mailing Address - Phone:520-271-4685
Mailing Address - Fax:520-297-1956
Practice Address - Street 1:7058 W PEBBLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85757-8745
Practice Address - Country:US
Practice Address - Phone:520-271-4685
Practice Address - Fax:520-297-1956
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP033661164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse