Healthcare Provider Details

I. General information

NPI: 1083096895
Provider Name (Legal Business Name): RANITA R KELLER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 TROY RD STE 130
EDWARDSVILLE IL
62025-2540
US

IV. Provider business mailing address

2122 TROY RD STE 130
EDWARDSVILLE IL
62025-2540
US

V. Phone/Fax

Practice location:
  • Phone: 618-800-4500
  • Fax:
Mailing address:
  • Phone: 618-800-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2015032216
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277000539
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: