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General NPI Number Information
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NPI Number | 1013458454
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Entity Type | Individual
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Provider Name | KELLY LIESSE MD
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Gender | Female
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Dates
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Enumeration Date | 03/18/2017
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Last Update Date | 08/13/2023
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Provider Practice Location Address
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Address Line | 3522 10TH ST NW
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City | WASHINGTON
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State | DC
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Zip | 20010-1480
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Country | US
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Telephone | 630-660-0161
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Fax |
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Provider Business Mailing Address
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Address Line | 3522 10TH ST NW
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City | WASHINGTON
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State | DC
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Zip | 20010-1480
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Country | US
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Telephone | 630-660-0161
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 036.152067
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A172837
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD210011400
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License Number State | DC
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