Healthcare Provider Details

I. General information

NPI: 1205416526
Provider Name (Legal Business Name): PEGGY SUE MORT KELLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2021
Last Update Date: 04/11/2021
Certification Date: 04/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 E PITTSBURGH ST
GREENSBURG PA
15601-2602
US

IV. Provider business mailing address

198 TROUTTOWN RD
HUNKER PA
15639-1288
US

V. Phone/Fax

Practice location:
  • Phone: 724-834-0960
  • Fax:
Mailing address:
  • Phone: 724-396-7995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN614382
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: