Healthcare Provider Details

I. General information

NPI: 1124546684
Provider Name (Legal Business Name): AMY KELLER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 MONROE ST
PETOSKEY MI
49770-2266
US

IV. Provider business mailing address

521 MONROE ST
PETOSKEY MI
49770-2266
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-1900
  • Fax: 231-348-0984
Mailing address:
  • Phone: 231-487-1900
  • Fax: 231-348-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704269377
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: