Healthcare Provider Details

I. General information

NPI: 1144336876
Provider Name (Legal Business Name): GERALD LOUIS KELLER JR. CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10435 CLAYTON RD
FRONTENAC MO
63131-2909
US

IV. Provider business mailing address

543 MINUS DR
SAINT PETERS MO
63376-4089
US

V. Phone/Fax

Practice location:
  • Phone: 314-995-3990
  • Fax:
Mailing address:
  • Phone: 636-397-4512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number079627
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: