Provider Demographics
NPI:1831441831
Name:KELLER, STACEY LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7072 MEARS GATE DR NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-8850
Mailing Address - Country:US
Mailing Address - Phone:330-966-1319
Mailing Address - Fax:330-966-1321
Practice Address - Street 1:7072 MEARS GATE DR NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-8850
Practice Address - Country:US
Practice Address - Phone:330-966-1319
Practice Address - Fax:330-966-1321
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-003643363A00000X
OH50003643363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086155Medicaid