Healthcare Provider Details

I. General information

NPI: 1376273672
Provider Name (Legal Business Name): MARCEA LEE KELLER DNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4897
US

IV. Provider business mailing address

2153 MOUNT OLIVE DR
SANTA ROSA CA
95404-5304
US

V. Phone/Fax

Practice location:
  • Phone: 707-322-9635
  • Fax:
Mailing address:
  • Phone: 707-328-4659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number534354
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: