Provider Demographics
NPI:1386037984
Name:KELLY, LESLIE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2735
Mailing Address - Country:US
Mailing Address - Phone:708-423-2662
Mailing Address - Fax:708-398-6926
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2735
Practice Address - Country:US
Practice Address - Phone:708-423-2662
Practice Address - Fax:708-398-6926
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily