Provider Demographics
NPI:1972279875
Name:KEELER, AMY LORAINE (MEDICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LORAINE
Last Name:KEELER
Suffix:
Gender:F
Credentials:MEDICAL ASSISTANT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LORAINE
Other - Last Name:LOCKWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 SE PARK CREST AVE APT A7
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8371
Mailing Address - Country:US
Mailing Address - Phone:360-606-4163
Mailing Address - Fax:
Practice Address - Street 1:11719 NE 95TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-2444
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA363AM0700XMedicaid