Provider Demographics
NPI:1851332688
Name:KELLER, THERESA M (NP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:1260 CROSSING MEADOWS DR
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8666
Practice Address - Country:US
Practice Address - Phone:608-775-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-064032363LF0000X
MN0192371-22363LF0000X
WI9675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076372Medicaid
MN01-07133OtherMEDICA
MN47G21KEOtherBLUE CROSS BLUE SHIELD
MN295450800Medicaid
MN500001717Medicare Oscar/Certification
MN295450800Medicaid
MNR22174Medicare UPIN