Provider Demographics
NPI:1417289935
Name:KELLY, LISA CATHERINE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CATHERINE
Last Name:KELLY
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 1:846 RITCHIE HWY
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-4150
Mailing Address - Country:US
Mailing Address - Phone:410-315-8877
Mailing Address - Fax:
Practice Address - Street 1:846 RITCHIE HWY
Practice Address - Street 2:SUITE 1A
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-4150
Practice Address - Country:US
Practice Address - Phone:410-315-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01793171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist