Basic Information
| Provider Information | |||||||||
| NPI: | 1831281427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | LYN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 N WYATT DR | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857126106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203243600 | ||||||||
| FaxNumber: | 5203243129 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 N WYATT DR | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857126106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203243600 | ||||||||
| FaxNumber: | 5203243129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | DA1516 | AZ | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 385775 | 05 | AZ | MEDICAID |