Healthcare Provider Details

I. General information

NPI: 1558407874
Provider Name (Legal Business Name): TINA LU KELLER RN, MSN, APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD 112U
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

1192 OAK GROVE DR
LOS ANGELES CA
90041-2418
US

V. Phone/Fax

Practice location:
  • Phone: 310-268-3447
  • Fax:
Mailing address:
  • Phone: 323-254-2751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number368873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: