Provider Demographics
NPI:1669457420
Name:KELLEY, LISA M (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2711 RANDOLPH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-2034
Mailing Address - Country:US
Mailing Address - Phone:704-342-9550
Mailing Address - Fax:704-377-0353
Practice Address - Street 1:2711 RANDOLPH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2034
Practice Address - Country:US
Practice Address - Phone:704-342-9550
Practice Address - Fax:704-377-0353
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024165508363LW0102X
NC0050-03621363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000974H83Medicare ID - Type Unspecified
P84088Medicare UPIN