Provider Demographics
NPI:1699055087
Name:KELLER, KRISTINA RAE (PT)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:RAE
Last Name:KELLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:KRISTY
Other - Middle Name:RAE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:16281 ESHER CT
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-5871
Mailing Address - Country:US
Mailing Address - Phone:419-796-9695
Mailing Address - Fax:
Practice Address - Street 1:16281 ESHER CT
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-5871
Practice Address - Country:US
Practice Address - Phone:419-796-9695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05010637A225100000X
OHPT-071970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist