Basic Information
| Provider Information | |||||||||
| NPI: | 1700191228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | ANN GRAINGER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 J H O'BRYAN AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RIVERS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703628246 | ||||||||
| FaxNumber: | 2703629757 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 HOSPITAL DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420788043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709883298 | ||||||||
| FaxNumber: | 2709884642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2010 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 1099069 | KY | N | Nursing Service Providers | Registered Nurse | Emergency | 363LF0000X | 3006643 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 3006643 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3006643 | 01 | KY | KBN | OTHER | 7100160340 | 05 | KY | MEDICAID |