Provider Demographics
NPI:1356319800
Name:LELAND, KELLI B (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:B
Last Name:LELAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3054
Mailing Address - Country:US
Mailing Address - Phone:218-829-2861
Mailing Address - Fax:
Practice Address - Street 1:221 MAIN ST N
Practice Address - Street 2:
Practice Address - City:PIERZ
Practice Address - State:MN
Practice Address - Zip Code:56364-1570
Practice Address - Country:US
Practice Address - Phone:320-468-2587
Practice Address - Fax:320-468-6219
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN037090800Medicaid
MN037090800Medicaid