Healthcare Provider Details

I. General information

NPI: 1972488435
Provider Name (Legal Business Name): TARA RENEE KELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 CLYO RD
DAYTON OH
45459-7000
US

IV. Provider business mailing address

356 N HAAS ST
FRANKENMUTH MI
48734-1106
US

V. Phone/Fax

Practice location:
  • Phone: 937-534-7330
  • Fax:
Mailing address:
  • Phone: 989-293-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1248198
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: