Provider Demographics
NPI:1851411235
Name:LEAKE, KELLI M (FNPC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:LEAKE
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4775
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4775
Mailing Address - Country:US
Mailing Address - Phone:713-798-5696
Mailing Address - Fax:713-798-1144
Practice Address - Street 1:6620 MAIN ST
Practice Address - Street 2:SUITE 1450
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2348
Practice Address - Country:US
Practice Address - Phone:713-798-7500
Practice Address - Fax:713-798-3487
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618474363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185566001Medicaid
TXQ45424Medicare UPIN
TX8L1481Medicare PIN
TX8J4002Medicare PIN