Provider Demographics
NPI:1619586195
Name:KELLER, ADELLE
Entity type:Individual
Prefix:
First Name:ADELLE
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MESSIMER DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1874
Mailing Address - Country:US
Mailing Address - Phone:740-522-8477
Mailing Address - Fax:
Practice Address - Street 1:3000 CORPORATE EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-7689
Practice Address - Country:US
Practice Address - Phone:614-400-7583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704381884363LP0808X
WAAP61291744363LP0808X
OHAPRN.CNP.0027218363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health