Provider Demographics
NPI:1689201337
Name:KEBALO-WALKER, LISA (APN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KEBALO-WALKER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 KNOLLCROFT RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NJ
Mailing Address - Zip Code:07939-5001
Mailing Address - Country:US
Mailing Address - Phone:732-259-6671
Mailing Address - Fax:
Practice Address - Street 1:151 KNOLLCROFT RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NJ
Practice Address - Zip Code:07939-5001
Practice Address - Country:US
Practice Address - Phone:732-259-6671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR11264700163WX1500X, 163WW0000X, 163WC2100X
NJ26NJ01018400261QV0200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WC2100XNursing Service ProvidersRegistered NurseContinence Care