Provider Demographics
NPI:1679158406
Name:KELLY, LISA JANE (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 QUIET CANYON DR
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-3262
Mailing Address - Country:US
Mailing Address - Phone:832-768-0986
Mailing Address - Fax:
Practice Address - Street 1:4710 QUIET CANYON DR
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-3262
Practice Address - Country:US
Practice Address - Phone:832-768-0986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX777596163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse