Provider Demographics
NPI:1902143324
Name:KELLER, KIM LYNNE (LPN)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LYNNE
Last Name:KELLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3220
Mailing Address - Country:US
Mailing Address - Phone:253-840-8881
Mailing Address - Fax:253-840-8992
Practice Address - Street 1:9610 168TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-2256
Practice Address - Country:US
Practice Address - Phone:253-840-8881
Practice Address - Fax:253-840-8992
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00037551164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse