Provider Demographics
NPI:1932539970
Name:KELLER, MANETTE (PT,DPT)
Entity Type:Individual
Prefix:MS
First Name:MANETTE
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 CORDOVA LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-7812
Mailing Address - Country:US
Mailing Address - Phone:504-259-5402
Mailing Address - Fax:870-931-4457
Practice Address - Street 1:2808 FOX MEADOW LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9346
Practice Address - Country:US
Practice Address - Phone:870-932-4245
Practice Address - Fax:870-931-4457
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist