Provider Demographics
NPI:1982008496
Name:BANKERT, KEELY
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:BANKERT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:
Other - Last Name:FRASIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 746071
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6071
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:4235 TUSCARAWAS ST W
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-5424
Practice Address - Country:US
Practice Address - Phone:234-203-4232
Practice Address - Fax:330-266-4386
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.16652363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112195Medicaid