Healthcare Provider Details

I. General information

NPI: 1922574938
Provider Name (Legal Business Name): SILENCE TIA KELLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 09/06/2021
Certification Date: 09/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26020 STATE ROAD 145
BRISTOW IN
47515-8865
US

IV. Provider business mailing address

PO BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 812-357-2099
  • Fax: 812-357-2097
Mailing address:
  • Phone: 812-996-8478
  • Fax: 812-996-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71008549A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008549A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: