Provider Demographics
NPI:1689394918
Name:KELLER, KAITLIN MARIE (PNP)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 PAPERBARK CT
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-1399
Mailing Address - Country:US
Mailing Address - Phone:309-369-7196
Mailing Address - Fax:
Practice Address - Street 1:3116 N DUKE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2102
Practice Address - Country:US
Practice Address - Phone:919-620-5333
Practice Address - Fax:919-471-8653
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBACK-W2YUI363LP0200X
NC5016813363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics