Basic Information
| Provider Information | |||||||||
| NPI: | 1912421074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | LEISHA | ||||||||
| MiddleName: | KAE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6110 SHALLOWFORD RD STE B | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234991031 | ||||||||
| FaxNumber: | 4232966384 | ||||||||
| Practice Location | |||||||||
| Address1: | 6110 SHALLOWFORD ROAD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234991031 | ||||||||
| FaxNumber: | 4232966384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 86055 | TN | N | Nursing Service Providers | Licensed Practical Nurse | 164W00000X | 56055 | TN | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.