Provider Demographics
NPI:1235537580
Name:KELLY, LISA-ANN
Entity Type:Individual
Prefix:
First Name:LISA-ANN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LISA-ANN
Other - Middle Name:
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:150 HINCHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2360
Mailing Address - Country:US
Mailing Address - Phone:973-595-6996
Mailing Address - Fax:973-595-6706
Practice Address - Street 1:150 HINCHMAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2360
Practice Address - Country:US
Practice Address - Phone:973-595-6996
Practice Address - Fax:973-595-6706
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN09168300363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7671008Medicaid
020304Medicare PIN
NJ7671008Medicaid