Provider Demographics
NPI:1699137455
Name:LIS, KALAN
Entity type:Individual
Prefix:
First Name:KALAN
Middle Name:
Last Name:LIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 POWELL BLVD
Mailing Address - Street 2:APT 14107
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-8141
Mailing Address - Country:US
Mailing Address - Phone:321-213-5408
Mailing Address - Fax:
Practice Address - Street 1:115 POWELL BLVD
Practice Address - Street 2:APT 14107
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-8141
Practice Address - Country:US
Practice Address - Phone:321-213-5408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other