Provider Demographics
NPI:1871390856
Name:KELLER, MADYSEN LYNN (PTA)
Entity type:Individual
Prefix:
First Name:MADYSEN
Middle Name:LYNN
Last Name:KELLER
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 PARK CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5081
Mailing Address - Country:US
Mailing Address - Phone:704-323-3200
Mailing Address - Fax:
Practice Address - Street 1:710 PARK CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5081
Practice Address - Country:US
Practice Address - Phone:704-323-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8553225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant