Provider Demographics
NPI:1356729453
Name:KELLER, ADAM D
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:D
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362
Mailing Address - Country:US
Mailing Address - Phone:334-255-7028
Mailing Address - Fax:334-255-7210
Practice Address - Street 1:301 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:342-557-0283
Practice Address - Fax:344-255-7210
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02974363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program