MEDICARE: LORI SUE KELLER FNP

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	363LF0000X	Family Nurse Practitioner	227099	AZ

General Provider Information

NPI Number	:	1700438272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI SUE KELLER FNP

Provider Business Mailing Address
First Line	:	1220 E TREMAINE AVE
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85234-4879
Country	:	US
Telephone Number	:	480-849-6255
Fax Number	:

Provider Business Practice Location Address
First Line	:	15255 N 40TH ST STE 135
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4682
Country	:	US
Telephone Number	:	480-417-5289
Fax Number	:

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

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	02/07/2022

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