Healthcare Provider Details

I. General information

NPI: 1760459887
Provider Name (Legal Business Name): LISA KEITHLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8186 LARK BROWN RD STE 203
ELKRIDGE MD
21075-6434
US

IV. Provider business mailing address

8186 LARK BROWN RD STE 203
ELKRIDGE MD
21075-6434
US

V. Phone/Fax

Practice location:
  • Phone: 410-799-8931
  • Fax: 441-799-8668
Mailing address:
  • Phone: 410-799-8931
  • Fax: 410-799-8668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0056088
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: