Healthcare Provider Details

I. General information

NPI: 1427033729
Provider Name (Legal Business Name): MS. SUSAN CAROL KEISTER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 NW 27TH AVENUE
CORVALLIS OR
97330
US

IV. Provider business mailing address

2305 NW 13TH ST
CORVALLIS OR
97330-1431
US

V. Phone/Fax

Practice location:
  • Phone: 541-766-6835
  • Fax: 541-847-5144
Mailing address:
  • Phone: 541-740-0630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: