MEDICARE: LAKEISHA KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	2021016504	MO

General Provider Information

NPI Number	:	1194496307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEISHA KELLY

Provider Business Mailing Address
First Line	:	6119 N EVANS AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-2162
Country	:	US
Telephone Number	:	816-868-0788
Fax Number	:

Provider Business Practice Location Address
First Line	:	6119 N EVANS AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-2162
Country	:	US
Telephone Number	:	816-868-0788
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2021
Last Update Date	:	09/27/2021

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Directions to “ LAKEISHA KELLY ” Practice Location

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