Provider Demographics
NPI:1689005381
Name:KELZ, LISA MARY (RN-BSN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARY
Last Name:KELZ
Suffix:
Gender:F
Credentials:RN-BSN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MADSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1215 SW G. STREET
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-2544
Mailing Address - Country:US
Mailing Address - Phone:541-476-2373
Mailing Address - Fax:541-476-1526
Practice Address - Street 1:1215 SW G. STREET
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-2544
Practice Address - Country:US
Practice Address - Phone:541-476-2373
Practice Address - Fax:541-476-1526
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR077039614RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health