Provider Demographics
NPI:1700191228
Name:KELLER, LEE ANN GRAINGER (ARNP, RN)
Entity Type:Individual
Prefix:MRS
First Name:LEE
Middle Name:ANN GRAINGER
Last Name:KELLER
Suffix:
Gender:F
Credentials:ARNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 J H O'BRYAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RIVERS
Mailing Address - State:KY
Mailing Address - Zip Code:42045
Mailing Address - Country:US
Mailing Address - Phone:270-362-8246
Mailing Address - Fax:270-362-9757
Practice Address - Street 1:141 HOSPITAL DR STE 102
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:KY
Practice Address - Zip Code:42078-8043
Practice Address - Country:US
Practice Address - Phone:270-988-3298
Practice Address - Fax:270-988-4642
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1099069163WE0003X
KY3006643363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3006643OtherKBN
KY7100160340Medicaid