Provider Demographics
NPI:1598112062
Name:LEM, KELLI NICOLE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:NICOLE
Last Name:LEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2989 MARBLE STONE AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-1689
Mailing Address - Country:US
Mailing Address - Phone:424-208-4630
Mailing Address - Fax:
Practice Address - Street 1:13900 MARQUESAS WAY APT 5417
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6076
Practice Address - Country:US
Practice Address - Phone:424-208-4630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-15
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53766261QU0200X
NVPA2010363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care