Provider Demographics
NPI:1831385772
Name:LISENBY, KELLIE LYNN (MNSC, CPNP)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:LYNN
Last Name:LISENBY
Suffix:
Gender:F
Credentials:MNSC, CPNP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:LYNN
Other - Last Name:CYRUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN BSN
Mailing Address - Street 1:1 CHILDRENS WAY
Mailing Address - Street 2:SLOT 837
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-4468
Mailing Address - Fax:501-364-1516
Practice Address - Street 1:1 CHILDRENS WAY
Practice Address - Street 2:SLOT 837
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-4468
Practice Address - Fax:501-364-1516
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03042363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5V826Medicare PIN