Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175F00000X | Naturopath | MT4261 | ME |
NPI | 1003292509 |
---|---|
Provider Name | Lisa Kelley |
First Address | South Portland, ME 04106-2232 |
Second Address | Portland, ME 04106 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2015 |
Last Update Date | 06/08/2015 |