Healthcare Provider Details

I. General information

NPI: 1013458454
Provider Name (Legal Business Name): KELLY LIESSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2017
Last Update Date: 08/13/2023
Certification Date: 08/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3522 10TH ST NW
WASHINGTON DC
20010-1480
US

IV. Provider business mailing address

3522 10TH ST NW
WASHINGTON DC
20010-1480
US

V. Phone/Fax

Practice location:
  • Phone: 630-660-0161
  • Fax:
Mailing address:
  • Phone: 630-660-0161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.152067
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA172837
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD210011400
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: