Provider Demographics
NPI:1508066309
Name:KELLER, LISA ANN (PNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:KELLER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 E THOMAS RD
Mailing Address - Street 2:BUILDING 2108, SUITE 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7710
Mailing Address - Country:US
Mailing Address - Phone:602-512-8029
Mailing Address - Fax:602-512-8161
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:EAST BUILDING
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-546-1900
Practice Address - Fax:602-546-1918
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN118987/AP2738363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics