MEDICARE: MRS. LACEE A 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	085004126	IL

General Provider Information

NPI Number	:	1417232059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LACEE A KELLER PA-C

Provider Business Mailing Address
First Line	:	25 E SCHAUMBURG RD STE 101
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60194-3548
Country	:	US
Telephone Number	:	847-252-6090
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 E SCHAUMBURG RD STE 101
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60194-3548
Country	:	US
Telephone Number	:	847-252-6090
Fax Number	:

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

Provider Enumeration Date	:	10/14/2011
Last Update Date	:	05/16/2023

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