Provider Demographics
NPI:1962514091
Name:KELLER, SUSAN LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 E CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-2223
Mailing Address - Country:US
Mailing Address - Phone:559-225-6100
Mailing Address - Fax:559-228-5309
Practice Address - Street 1:2615 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2223
Practice Address - Country:US
Practice Address - Phone:559-225-6100
Practice Address - Fax:559-228-5309
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3275174400000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03176ZMedicare ID - Type Unspecified