Healthcare Provider Details

I. General information

NPI: 1497437628
Provider Name (Legal Business Name): NICOLE MARIE KELLER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047B JOHN SIMS PKWY E
NICEVILLE FL
32578-2712
US

IV. Provider business mailing address

1047B JOHN SIMS PKWY E
NICEVILLE FL
32578-2712
US

V. Phone/Fax

Practice location:
  • Phone: 850-729-1086
  • Fax:
Mailing address:
  • Phone: 850-729-1086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT44910
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1379788
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: