Healthcare Provider Details

I. General information

NPI: 1972357796
Provider Name (Legal Business Name): KELLIE LEDAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3965 PHELAN BLVD STE 104
BEAUMONT TX
77707-2253
US

IV. Provider business mailing address

5595 BONNIE LEE ST
BEAUMONT TX
77705-6006
US

V. Phone/Fax

Practice location:
  • Phone: 832-693-2213
  • Fax:
Mailing address:
  • Phone: 832-693-2213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberP8WUN1JA8R
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberP8WUN1JA8R
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: