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General NPI Number Information
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NPI Number | 1174016646
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Entity Type | Individual
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Provider Name | LISA KELLER
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Gender | Female
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Dates
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Enumeration Date | 06/10/2018
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Last Update Date | 05/01/2023
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Provider Practice Location Address
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Address Line | 6838 YELLOWSTONE BLVD APT B43
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City | FOREST HILLS
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State | NY
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Zip | 11375-3426
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Country | US
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Telephone | 516-375-2942
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Fax |
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Provider Business Mailing Address
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Address Line | 576 LONGACRE AVE
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City | WOODMERE
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State | NY
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Zip | 11598-2308
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Country | US
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Telephone | 516-375-2942
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | F351233
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 747652
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License Number State | NY
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