Provider Demographics
NPI:1104266188
Name:MITCHELL, KELLY LESHAWN (LPN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LESHAWN
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:238 LAWRENCE AVE
Mailing Address - Street 2:APARTMENT#9
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1297
Mailing Address - Country:US
Mailing Address - Phone:516-425-3686
Mailing Address - Fax:516-425-3686
Practice Address - Street 1:238 LAWRENCE AVE
Practice Address - Street 2:APARTMENT#9
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1297
Practice Address - Country:US
Practice Address - Phone:516-425-3686
Practice Address - Fax:516-425-3686
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268539-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse