Provider Demographics
NPI:1194776013
Name:KEITH, LISA M (ARNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KEITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8890 N UNION BLVD STE 170
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-2701
Mailing Address - Country:US
Mailing Address - Phone:719-364-5005
Mailing Address - Fax:719-365-9911
Practice Address - Street 1:175 S UNION BLVD STE 300
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3126
Practice Address - Country:US
Practice Address - Phone:719-364-5005
Practice Address - Fax:719-365-9911
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO100283363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIQ00055Medicare UPIN
HIH55919Medicare ID - Type Unspecified