Provider Demographics
NPI:1447504634
Name:KELLEY, LISA M (RN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 PINNACLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:13167-4167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:93 BARKER RD
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-3460
Practice Address - Country:US
Practice Address - Phone:315-668-4253
Practice Address - Fax:315-668-4299
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY51338-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY51338-1Medicaid