Provider Demographics
NPI:1639458870
Name:KELLER, JULIE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9240 BRUCKHAUS ST
Mailing Address - Street 2:APARTMENT 2-315
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4401
Mailing Address - Country:US
Mailing Address - Phone:919-880-1751
Mailing Address - Fax:
Practice Address - Street 1:4414 LAKE BOONE TRL
Practice Address - Street 2:SUITE 402
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7513
Practice Address - Country:US
Practice Address - Phone:919-784-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-03041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant