Provider Demographics
NPI:1740057108
Name:KELLER, REBECCA JEAN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
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:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:HOVLAND
Mailing Address - State:MN
Mailing Address - Zip Code:55606-0082
Mailing Address - Country:US
Mailing Address - Phone:218-387-4470
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-268-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95316348163W00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health