Provider Demographics
NPI:1457575037
Name:KECKLER, LISA ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELLEN
Last Name:KECKLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15774 W WEDGE WAY
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:CO
Mailing Address - Zip Code:80465-2146
Mailing Address - Country:US
Mailing Address - Phone:209-345-6690
Mailing Address - Fax:
Practice Address - Street 1:100 HEALTH PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9583
Practice Address - Country:US
Practice Address - Phone:303-673-1102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP378406363LN0005X
CO0191601363LN0005X, 363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care