Healthcare Provider Details

I. General information

NPI: 1245582493
Provider Name (Legal Business Name): KELLEY ELIZABETH LEMON M.HRD, ATC/LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SANDPIPER LN
ORMOND BEACH FL
32174-4264
US

IV. Provider business mailing address

50 SANDPIPER LN
ORMOND BEACH FL
32174-4264
US

V. Phone/Fax

Practice location:
  • Phone: 850-559-1419
  • Fax:
Mailing address:
  • Phone: 850-559-1419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL3146
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: