MEDICARE: DALE V KELLER APRN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2239484405	UT

General Provider Information

NPI Number	:	1477519882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE V KELLER APRN

Provider Business Mailing Address
First Line	:	12218 NICKLAUS RD
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-5937
Country	:	US
Telephone Number	:	801-502-7386
Fax Number	:

Provider Business Practice Location Address
First Line	:	12218 NICKLAUS RD
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-5937
Country	:	US
Telephone Number	:	801-502-7386
Fax Number	:

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	04/27/2016

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