Provider Demographics
NPI:1912317629
Name:KELLY, LISA A (APRN,NP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:APRN,NP-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:MESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9816
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-201-5019
Practice Address - Street 1:116 HILLS PLZ
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2438
Practice Address - Country:US
Practice Address - Phone:304-720-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1912317629Medicaid
WVWV4931B663Medicare PIN
WVWV4931BMedicare PIN
WVWV4931CMedicare PIN
WVWV4931GMedicare PIN
WVWV4931B662Medicare PIN
WV3810028232Medicaid
WVWV4931DMedicare PIN
WVWV4931EMedicare PIN
WVWV4931FMedicare PIN