Healthcare Provider Details

I. General information

NPI: 1942339007
Provider Name (Legal Business Name): COLLEEN KELLER FNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 3RD ST
PHOENIX AZ
85004-2129
US

IV. Provider business mailing address

1402 E HUBBELL ST
PHOENIX AZ
85006-1751
US

V. Phone/Fax

Practice location:
  • Phone: 602-496-0782
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN032560
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberFNP 369
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: