Provider Demographics
NPI:1417505058
Name:KELLER, TANYA DAWN (FNP-C, APRN)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:DAWN
Last Name:KELLER
Suffix:
Gender:F
Credentials:FNP-C, APRN
Other - Prefix:MS
Other - First Name:TANYA
Other - Middle Name:DAWN
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C, APRN
Mailing Address - Street 1:754 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-415-9600
Mailing Address - Fax:276-415-9601
Practice Address - Street 1:754 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-415-9600
Practice Address - Fax:276-415-9601
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26640363LF0000X
VA0024177408363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
6430761947001OtherSURESCRIPTS