Provider Demographics
NPI:1164075453
Name:KELLY, LISA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E FRONT ST APT B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-2269
Mailing Address - Country:US
Mailing Address - Phone:734-497-9041
Mailing Address - Fax:
Practice Address - Street 1:10 E FRONT ST APT B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-2269
Practice Address - Country:US
Practice Address - Phone:734-497-9041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704176148363L00000X
FL9402875363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner