MEDICARE: MARY KELLER PMHNP-BC, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5019419	NC
2	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	RN311520	GA

General Provider Information

NPI Number	:	1427782861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KELLER PMHNP-BC, RN

Provider Business Mailing Address
First Line	:	12244 AUGUSTA RD UNIT 108
Second Line	:
City	:	LAVONIA
State	:	GA
Zip	:	30553-1210
Country	:	US
Telephone Number	:	706-963-0654
Fax Number	:	706-973-4087

Provider Business Practice Location Address
First Line	:	24 CHECHERO ST STE 2
Second Line	:
City	:	CLAYTON
State	:	GA
Zip	:	30525-6181
Country	:	US
Telephone Number	:	706-963-0654
Fax Number	:	706-973-4087

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2022
Last Update Date	:	01/21/2026

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