Provider Demographics
NPI:1669129458
Name:KELLER, NICOLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3440 DECLARATION BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-8139
Mailing Address - Country:US
Mailing Address - Phone:803-905-3278
Mailing Address - Fax:803-905-3282
Practice Address - Street 1:3440 DECLARATION BLVD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154-8139
Practice Address - Country:US
Practice Address - Phone:803-905-3278
Practice Address - Fax:803-905-3282
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA.4324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant