Provider Demographics
NPI:1053116558
Name:KELLER, HEIDI M (LPN)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:M
Last Name:KELLER
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:M
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1320 WOODMAN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-3497
Mailing Address - Country:US
Mailing Address - Phone:937-223-1781
Mailing Address - Fax:937-424-0279
Practice Address - Street 1:1320 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-3497
Practice Address - Country:US
Practice Address - Phone:937-223-1781
Practice Address - Fax:937-424-0279
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.170046.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse