=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831441831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY LYNN KELLER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2012
-----------------------------------------------------
Last Update Date | 03/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7072 MEARS GATE DR NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-8850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-966-1319
-----------------------------------------------------
Fax | 330-966-1321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7072 MEARS GATE DR NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-8850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-966-1319
-----------------------------------------------------
Fax | 330-966-1321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 50-003643
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 50003643
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------