Provider Demographics
NPI:1609286848
Name:ELY, LISA KIRSTEN (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KIRSTEN
Last Name:ELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1250 E. MARSHALL ST.
Mailing Address - Street 2:BOX 980034
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298
Mailing Address - Country:US
Mailing Address - Phone:804-828-9360
Mailing Address - Fax:804-828-2448
Practice Address - Street 1:1400 FOREST GLEN RD STE 500
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910
Practice Address - Country:US
Practice Address - Phone:301-681-6772
Practice Address - Fax:301-681-3424
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD0085795207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program