Provider Demographics
NPI:1518732312
Name:KELLY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
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 1:15 FRED DR
Mailing Address - Street 2:
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-7717
Mailing Address - Country:US
Mailing Address - Phone:570-407-2555
Mailing Address - Fax:
Practice Address - Street 1:809 HUNTER HWY STE 5
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-8070
Practice Address - Country:US
Practice Address - Phone:570-996-2700
Practice Address - Fax:570-996-2711
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004024133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered