Healthcare Provider Details

I. General information

NPI: 1447896147
Provider Name (Legal Business Name): KELLY LESLIE APRN-FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 VILLAGE HWY
RUSTBURG VA
24588-4591
US

IV. Provider business mailing address

134 ELON RD
MADISON HEIGHTS VA
24572-2536
US

V. Phone/Fax

Practice location:
  • Phone: 434-929-1400
  • Fax:
Mailing address:
  • Phone: 344-929-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP201331
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024182771
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: