Provider Demographics
NPI:1801932009
Name:KELLER, NICOLE W (PA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:W
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:WALSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:39 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7531
Practice Address - Country:US
Practice Address - Phone:239-936-1616
Practice Address - Fax:239-936-0837
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052764363AM0700X
FLPA9107690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010911000Medicaid
FL5923925OtherAETNA
FLP01304910OtherRAILROAD MCR
FL1026853OtherSTAYWELL (MEDICAID) AND WELLCARE (MEDICARE).
FL398591OtherAVMED
FLY0M11OtherBCBS
FLP1023102OtherFREEDOM
FLP961366OtherOPTIMUM