Provider Demographics
NPI:1720727175
Name:KELLER, JUSTIN DANIEL (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DANIEL
Last Name:KELLER
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-2506
Mailing Address - Country:US
Mailing Address - Phone:610-241-2444
Mailing Address - Fax:
Practice Address - Street 1:370 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-2506
Practice Address - Country:US
Practice Address - Phone:610-241-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA226652146L00000X
NJ26NR24419700163WE0003X
PARN756924163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No163WE0003XNursing Service ProvidersRegistered NurseEmergency