Provider Demographics
NPI:1861673204
Name:KELLER, LINDA MAYE
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:MAYE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LLINDA
Other - Middle Name:MAYE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4646 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6842
Mailing Address - Country:US
Mailing Address - Phone:260-436-6544
Mailing Address - Fax:
Practice Address - Street 1:4646 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6842
Practice Address - Country:US
Practice Address - Phone:260-436-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC17211332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1135630001Medicare NSC