Provider Demographics
NPI:1881199834
Name:LESOON, KELLY S (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:LESOON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 E ANAHEIM ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-5515
Mailing Address - Country:US
Mailing Address - Phone:562-270-0324
Mailing Address - Fax:
Practice Address - Street 1:1360 E ANAHEIM ST STE 101
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-5515
Practice Address - Country:US
Practice Address - Phone:562-270-0324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95007732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily