Provider Demographics
NPI:1174016646
Name:KELLER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 LONGACRE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2308
Mailing Address - Country:US
Mailing Address - Phone:516-375-2942
Mailing Address - Fax:
Practice Address - Street 1:6838 YELLOWSTONE BLVD APT B43
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3426
Practice Address - Country:US
Practice Address - Phone:516-375-2942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-10
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY747652163W00000X
NYF351233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse