=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750934139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETH KELLER FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2019
-----------------------------------------------------
Last Update Date | 07/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 E 20TH AVE
-----------------------------------------------------
City | TORRINGTON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82240-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-269-0947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1315 HOWE RD
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82070-6888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 44270
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------