Provider Demographics
NPI:1447237516
Name:KELLEY, LISA (CNM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BARTLETT BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7737
Mailing Address - Country:US
Mailing Address - Phone:802-777-8997
Mailing Address - Fax:
Practice Address - Street 1:1775 WILLISTON RD
Practice Address - Street 2:SUITE 220
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6491
Practice Address - Country:US
Practice Address - Phone:802-861-0200
Practice Address - Fax:802-861-0210
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0014084367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT361683OtherMVP
VT5207602OtherVERMONT MANAGED CARE
VT00059280OtherBCBS
VT1009149Medicaid
VTVN3125Medicare ID - Type Unspecified
VT361683OtherMVP