Healthcare Provider Details

I. General information

NPI: 1639586209
Provider Name (Legal Business Name): JENNIFER E. KELLER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER E LUFT FNP

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 N 22ND ST UNIT A
LARAMIE WY
82072
US

IV. Provider business mailing address

205 CORTHELL RD
LARAMIE WY
82070-4827
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-5364
  • Fax:
Mailing address:
  • Phone: 307-399-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number336651808
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33665.1808
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: