Provider Demographics
NPI:1720061203
Name:GONDEK KELLY, LISA M (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GONDEK KELLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:300 E MCBEE AVE
Mailing Address - Street 2:FL 4
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE PT STE 300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4569
Practice Address - Country:US
Practice Address - Phone:864-522-3700
Practice Address - Fax:864-522-3705
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC525367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400097OtherMEDICAID - GROUP
SC1152OtherMEDICARE - GROUP
SCAN0929Medicaid
SCGP2991Medicaid
SC68777Medicare ID - Type UnspecifiedGROUP
SC1152OtherMEDICARE - GROUP