Provider Demographics
NPI:1871760769
Name:KEELER-ROBERTS, JOANNE SUE (CN)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:SUE
Last Name:KEELER-ROBERTS
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 MANITOU AVE
Mailing Address - Street 2:
Mailing Address - City:MANITOU SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80829-2910
Mailing Address - Country:US
Mailing Address - Phone:719-650-4584
Mailing Address - Fax:719-687-8055
Practice Address - Street 1:1107 MANITOU AVE
Practice Address - Street 2:
Practice Address - City:MANITOU SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80829-2910
Practice Address - Country:US
Practice Address - Phone:719-650-4584
Practice Address - Fax:719-687-8055
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-11
Last Update Date:2008-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO611510133N00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education