Provider Demographics
NPI:1831656396
Name:KIPPLEY, LISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KIPPLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18275 KENRICK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-7306
Mailing Address - Country:US
Mailing Address - Phone:651-234-2950
Mailing Address - Fax:
Practice Address - Street 1:18275 KENRICK AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7306
Practice Address - Country:US
Practice Address - Phone:651-234-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant