Provider Demographics
NPI:1164620373
Name:KILLIAN, LISA M (RN CCM)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:KILLIAN
Suffix:
Gender:F
Credentials:RN CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 BLUE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526
Mailing Address - Country:US
Mailing Address - Phone:585-298-1544
Mailing Address - Fax:
Practice Address - Street 1:112 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616
Practice Address - Country:US
Practice Address - Phone:585-865-3046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4245201163W00000X, 163WC0400X, 163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02679596Medicaid