Healthcare Provider Details

I. General information

NPI: 1174792618
Provider Name (Legal Business Name): JOY KELLER CDM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 30TH AVE
FAIRBANKS AK
99701-7316
US

IV. Provider business mailing address

2054 30TH AVE
FAIRBANKS AK
99701-7316
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-3719
  • Fax: 907-456-1511
Mailing address:
  • Phone: 907-456-3719
  • Fax: 907-456-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberAA54
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: