Healthcare Provider Details

I. General information

NPI: 1174059620
Provider Name (Legal Business Name): ELIZABETH KELLER LOLLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH KELLER MD

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HILLCREST MEDICAL BLVD STE 300
WACO TX
76712-8951
US

IV. Provider business mailing address

1600 PROVIDENCE DR
WACO TX
76707-2261
US

V. Phone/Fax

Practice location:
  • Phone: 254-313-6500
  • Fax:
Mailing address:
  • Phone: 254-313-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberS2613
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: