Provider Demographics
NPI:1306800131
Name:KELLER, JOANNE M (ARNP)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3643 LAKE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2364
Mailing Address - Country:US
Mailing Address - Phone:352-385-2631
Mailing Address - Fax:352-385-2639
Practice Address - Street 1:3643 LAKE CENTER DR
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2364
Practice Address - Country:US
Practice Address - Phone:352-385-2631
Practice Address - Fax:352-385-2639
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3371562363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0232ZOtherMEDICARE PTAN
FL304050000Medicaid
FL304050000Medicaid