MEDICARE: DANIELLE DOMINIQUE KELLER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	11145	AZ

General Provider Information

NPI Number	:	1366075814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE DOMINIQUE KELLER PA-C

Provider Business Mailing Address
First Line	:	1330 N RIM DR STE A
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1330 N RIM DR STE A
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-3138
Country	:	US
Telephone Number	:	661-843-6420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2020
Last Update Date	:	12/10/2025

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