=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467351635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDRA RENEE KELLER PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2026
-----------------------------------------------------
Last Update Date | 11/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3105 NASH ST NW STE 205
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27896-1235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 984-919-2584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3409 MILLBROOK DR SW
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27893-9272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-314-2326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 5025852
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------