Provider Demographics
NPI:1902991466
Name:KELLER, STEPHANNIE L
Entity Type:Individual
Prefix:
First Name:STEPHANNIE
Middle Name:L
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DOUBLE IMANGE, INC. DBA PEARLE VISION
Mailing Address - Street 2:3001 WHITE BEAR AVE., NO., SUITE 1050
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109
Mailing Address - Country:US
Mailing Address - Phone:651-770-3923
Mailing Address - Fax:952-435-2624
Practice Address - Street 1:DOUBLE IMANGE, INC. DBA PEARLE VISION
Practice Address - Street 2:3001 WHITE BEAR AVE., NO., SUITE 1050
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-770-3923
Practice Address - Fax:952-435-2624
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1242230002Medicare ID - Type UnspecifiedMEDICAL DURABLE GOODS