Healthcare Provider Details

I. General information

NPI: 1508791096
Provider Name (Legal Business Name): LESLIE I KELM PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 FOREST MEADOW LN
ORANGE PARK FL
32065-5618
US

IV. Provider business mailing address

436 FOREST MEADOW LN
ORANGE PARK FL
32065-5618
US

V. Phone/Fax

Practice location:
  • Phone: 956-564-0073
  • Fax:
Mailing address:
  • Phone: 956-564-0073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11048052
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: