Provider Demographics
NPI:1952307381
Name:KELLER, KELLY A (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KADARI
Other - Middle Name:
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:420 WHITEHALL RD
Mailing Address - Street 2:UNIT B
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6135
Mailing Address - Country:US
Mailing Address - Phone:510-589-9902
Mailing Address - Fax:510-263-8565
Practice Address - Street 1:420 WHITEHALL RD APT B
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-6135
Practice Address - Country:US
Practice Address - Phone:510-589-9902
Practice Address - Fax:510-263-8565
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12688363LP0808X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ28819Medicare UPIN
CAZZZ314072ZMedicare ID - Type Unspecified