Basic Information
Provider Information | |||||||||
NPI: | 1639586209 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLER | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUFT | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | E | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 205 CORTHELL RD | ||||||||
Address2: |   | ||||||||
City: | LARAMIE | ||||||||
State: | WY | ||||||||
PostalCode: | 820704827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073997133 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1252 N 22ND ST UNIT A | ||||||||
Address2: |   | ||||||||
City: | LARAMIE | ||||||||
State: | WY | ||||||||
PostalCode: | 82072 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077455364 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2014 | ||||||||
LastUpdateDate: | 01/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 336651808 | WY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | 33665.1808 | WY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 33665.1808 | 01 | WY | WYOMING STATE BOARD OF NURSING | OTHER |