Provider Demographics
NPI:1114202603
Name:KELLER, NICHOLE L (PHD)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:L
Last Name:KELLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 N 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-1149
Mailing Address - Country:US
Mailing Address - Phone:140-259-4506
Mailing Address - Fax:
Practice Address - Street 1:1827 N 103RD AVENUE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-1149
Practice Address - Country:US
Practice Address - Phone:402-594-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12964183500000X
IA20887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist