Provider Demographics
NPI:1194156067
Name:KEOWN, LISA KAY (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KAY
Last Name:KEOWN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KAY
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-577-4200
Practice Address - Fax:317-577-9503
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011058367500000X
IN28097300A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00372317OtherRAILROAD PTAN
IN1102387917OtherANTHEM PTAN
IN000001100047OtherANTHEM PROVIDER NUMBER
IN000001664800OtherANTHEM PTAN
IN300005321Medicaid