Provider Demographics
NPI:1427158310
Name:KELLER, AUTUMN RENEE (DC)
Entity type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:RENEE
Last Name:KELLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MISS
Other - First Name:AUTUMN
Other - Middle Name:RENEE
Other - Last Name:DONATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:813 TAPPAN ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-3557
Mailing Address - Country:US
Mailing Address - Phone:419-887-1531
Mailing Address - Fax:
Practice Address - Street 1:659 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-2701
Practice Address - Country:US
Practice Address - Phone:419-698-2008
Practice Address - Fax:419-698-2640
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3204111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4066521Medicaid
OHKE4066521Medicare ID - Type Unspecified
OH4066521Medicaid