MEDICARE: SUSAN KELLER APN,

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	363L00000X	Nurse Practitioner	209001731	IL

General Provider Information

NPI Number	:	1598736514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KELLER APN,

Provider Business Mailing Address
First Line	:	4500 MEMORIAL DRIVE CREDENTIALING DEPARTMENT
Second Line	:	MEMORIAL HOSPITAL MEDICAL AFFAIRS
City	:	BELLEVILLE
State	:	IL
Zip	:	62226
Country	:	US
Telephone Number	:	618-257-4644
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 LINCOLN PLACE CT
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-5884
Country	:	US
Telephone Number	:	618-257-2029
Fax Number	:

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

Provider Enumeration Date	:	01/28/2006
Last Update Date	:	10/22/2015

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