1447237516 NPI number — LISA KELLEY C.N.M.

Table of content: LISA KELLEY C.N.M. (NPI 1447237516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447237516 NPI number — LISA KELLEY C.N.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
C.N.M.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447237516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 BARTLETT BAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05403-7737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-777-8997
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1775 WILLISTON RD
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
SOUTH BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05403-6491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-861-0200
Provider Business Practice Location Address Fax Number:
802-861-0210
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  101-0014084 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 361683 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 5207602 . This is a "VERMONT MANAGED CARE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 00059280 . This is a "BCBS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1009149 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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