Basic Information
| Provider Information | |||||||||
| NPI: | 1720034127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLOGG | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152392018 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 REDBUD DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PORTLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371481617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153251206 | ||||||||
| FaxNumber: | 6153251245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1755 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33000032 | 05 | TN | MEDICAID | P00419528 | 01 | RAILROAD MEDICARE | OTHER | 33000031 | 01 | TN | MEDICARE TAX ID 201119913 | OTHER |