Provider Demographics
NPI:1982008496
Name:BANKERT, KEELY
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:BANKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:
Other - Last Name:FRASIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 6TH ST SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1702
Mailing Address - Country:US
Mailing Address - Phone:330-456-2695
Mailing Address - Fax:330-588-8605
Practice Address - Street 1:2600 6TH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44710-1702
Practice Address - Country:US
Practice Address - Phone:330-456-2695
Practice Address - Fax:330-588-8605
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16652-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112195Medicaid