Provider Demographics
NPI:1861768962
Name:KELLIE, LESLEY ANNE RAMOS
Entity type:Individual
Prefix:
First Name:LESLEY ANNE
Middle Name:RAMOS
Last Name:KELLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:100 MALLARD CREEK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4194
Practice Address - Country:US
Practice Address - Phone:502-855-6130
Practice Address - Fax:502-394-1968
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY03976207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK208000Medicare PIN