Healthcare Provider Details

I. General information

NPI: 1962017764
Provider Name (Legal Business Name): CARRIE ANNE KELDERMAN BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 JEFFERSON ST
PELLA IA
50219-1257
US

IV. Provider business mailing address

404 JEFFERSON ST
PELLA IA
50219-1257
US

V. Phone/Fax

Practice location:
  • Phone: 641-628-6613
  • Fax:
Mailing address:
  • Phone: 641-628-6613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-22096
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: