Provider Demographics
NPI:1013530005
Name:KEELEY, LISA (LVN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KEELEY
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 SWEENEY CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2885
Mailing Address - Country:US
Mailing Address - Phone:530-305-3384
Mailing Address - Fax:
Practice Address - Street 1:8946 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-4010
Practice Address - Country:US
Practice Address - Phone:530-305-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA705611164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALISAKEELEYMedicaid
CALISAKEELEYOtherALL OTHER INSURANCE