Provider Demographics
NPI:1316105075
Name:KELLER, LISA (CPNP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1675 HIGHLAND AVE
Mailing Address - Street 2:ROOM P4 4118
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0002
Mailing Address - Country:US
Mailing Address - Phone:608-890-8198
Mailing Address - Fax:608-265-9721
Practice Address - Street 1:1675 HIGHLAND AVE
Practice Address - Street 2:ROOM P4 4118
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0002
Practice Address - Country:US
Practice Address - Phone:608-890-8198
Practice Address - Fax:608-265-9721
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI104212-030163WP0200X
WI97062363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics