Provider Demographics
NPI:1881197457
Name:KELLER, KIMBERLY (FNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3100
Mailing Address - Country:US
Mailing Address - Phone:154-441-1806
Mailing Address - Fax:615-449-0883
Practice Address - Street 1:1616 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3100
Practice Address - Country:US
Practice Address - Phone:615-444-1180
Practice Address - Fax:615-449-0883
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23758363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN$$$$$$$$$Medicaid