Provider Demographics
NPI:1174059620
Name:LOLLEY, ELIZABETH KELLER (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KELLER
Last Name:LOLLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:
Practice Address - Street 1:120 HILLCREST MEDICAL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8951
Practice Address - Country:US
Practice Address - Phone:254-313-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS2613207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program