Healthcare Provider Details

I. General information

NPI: 1083540884
Provider Name (Legal Business Name): KELLY LEILICH WARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5809 MONET DR
ROANOKE VA
24018-5240
US

IV. Provider business mailing address

5809 MONET DR
ROANOKE VA
24018-5240
US

V. Phone/Fax

Practice location:
  • Phone: 443-803-1999
  • Fax:
Mailing address:
  • Phone: 443-803-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024197515
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: