Healthcare Provider Details

I. General information

NPI: 1073647624
Provider Name (Legal Business Name): NICOLE K KELLER AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 SUGAR CREEK CTR
BELLA VISTA AR
72714-3507
US

IV. Provider business mailing address

22 SUGAR CREEK CTR
BELLA VISTA AR
72714-3507
US

V. Phone/Fax

Practice location:
  • Phone: 479-876-0110
  • Fax: 479-876-0111
Mailing address:
  • Phone: 479-876-0110
  • Fax: 479-876-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA275
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: