Provider Demographics
NPI:1811378474
Name:KELLER, STEPHANIE MAE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MAE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MAE
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4989 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-9548
Mailing Address - Country:US
Mailing Address - Phone:307-745-8997
Mailing Address - Fax:307-742-6146
Practice Address - Street 1:4989 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-9548
Practice Address - Country:US
Practice Address - Phone:307-745-8997
Practice Address - Fax:307-742-6146
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker