Provider Demographics
NPI:1588976336
Name:KELLER, AMANDA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MARIE
Last Name:KELLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7275 CLOVER HILL DR
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-9451
Mailing Address - Country:US
Mailing Address - Phone:608-335-3221
Mailing Address - Fax:608-274-4031
Practice Address - Street 1:7050 WATTS RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1365
Practice Address - Country:US
Practice Address - Phone:608-274-4084
Practice Address - Fax:608-274-4031
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3179-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist