Provider Demographics
NPI:1720034127
Name:KELLOGG, LISA S (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:
Practice Address - Street 1:1531 HUNT CLUB BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-6096
Practice Address - Country:US
Practice Address - Phone:615-431-9930
Practice Address - Fax:615-431-9940
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00419528OtherRAILROAD MEDICARE
TN33000032Medicaid
TN33000031OtherMEDICARE TAX ID 201119913