Provider Demographics
NPI:1457410540
Name:KELLER, LISA (CRNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:C
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1240 S BROAD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5395
Mailing Address - Country:US
Mailing Address - Phone:215-361-3376
Mailing Address - Fax:215-412-3587
Practice Address - Street 1:1240 S BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-5395
Practice Address - Country:US
Practice Address - Phone:215-361-3376
Practice Address - Fax:215-412-3587
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009116363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ76876Medicare UPIN
PA108602Medicare PIN