Provider Demographics
NPI:1205946266
Name:KELLY, LESLIE R (APRN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:R
Last Name:KELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2052
Mailing Address - Country:US
Mailing Address - Phone:413-582-2441
Mailing Address - Fax:
Practice Address - Street 1:30 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2052
Practice Address - Country:US
Practice Address - Phone:413-582-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0021171363LF0000X
WI4902-33363L00000X
WI191800-30163W00000X
MA238190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIKELLYLESOtherMERCYCARE INSURANCE
WI1205946266Medicaid
MA110102297AMedicaid
VT1008712Medicaid
WI1205946266OtherBCBSWI
MA110102297AMedicaid
VTKE NP 3894Medicare ID - Type Unspecified