Provider Demographics
NPI:1619245792
Name:KELLEY, LISA LEIGH (LAC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LEIGH
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 PARK PL APT 3P
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4351
Mailing Address - Country:US
Mailing Address - Phone:206-406-0007
Mailing Address - Fax:
Practice Address - Street 1:1 UNION SQ W STE 715
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3303
Practice Address - Country:US
Practice Address - Phone:206-406-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004584-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist