Healthcare Provider Details

I. General information

NPI: 1164129136
Provider Name (Legal Business Name): DONNA KELTNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 02/10/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8591 S BROADWAY AVE
TYLER TX
75703-5470
US

IV. Provider business mailing address

781 SPENCER LN
TYLER TX
75704-6671
US

V. Phone/Fax

Practice location:
  • Phone: 903-606-8840
  • Fax:
Mailing address:
  • Phone: 903-747-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number681690
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: