Healthcare Provider Details

I. General information

NPI: 1114964772
Provider Name (Legal Business Name): JOHN A KELLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 E PARRISH AVE SUITE 460
OWENSBORO KY
42303-3222
US

IV. Provider business mailing address

5275 ISLAND FORD RD
MADISONVILLE KY
42431-9431
US

V. Phone/Fax

Practice location:
  • Phone: 270-684-5005
  • Fax: 270-926-4432
Mailing address:
  • Phone: 270-684-5005
  • Fax: 270-926-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2097A
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: