Healthcare Provider Details

I. General information

NPI: 1912421074
Provider Name (Legal Business Name): LEISHA KAE KELLY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 SHALLOWFORD ROAD SUITE B
CHATTANOOGA TN
37421
US

IV. Provider business mailing address

6110 SHALLOWFORD RD STE B
CHATTANOOGA TN
37421-1894
US

V. Phone/Fax

Practice location:
  • Phone: 423-499-1031
  • Fax: 423-296-6384
Mailing address:
  • Phone: 423-499-1031
  • Fax: 423-296-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number86055
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number56055
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: