Healthcare Provider Details

I. General information

NPI: 1447237516
Provider Name (Legal Business Name): LISA KELLEY C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 WILLISTON RD SUITE 220
SOUTH BURLINGTON VT
05403-6491
US

IV. Provider business mailing address

66 BARTLETT BAY RD
SOUTH BURLINGTON VT
05403-7737
US

V. Phone/Fax

Practice location:
  • Phone: 802-861-0200
  • Fax: 802-861-0210
Mailing address:
  • Phone: 802-777-8997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number101-0014084
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: