Provider Demographics
NPI:1609801729
Name:KELSEN, LISA M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KELSEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HIGH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7640
Mailing Address - Country:US
Mailing Address - Phone:207-795-2310
Mailing Address - Fax:207-753-7647
Practice Address - Street 1:10 HIGH ST STE 103
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-795-2310
Practice Address - Fax:207-753-7647
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP08137363LF0000X
AK973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL 9107Medicaid
AKCL 9107Medicaid
MEMK0662824OtherDEA NUMBER