Provider Demographics
NPI:1699445056
Name:KELLAM, LESLIE (DNP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:KELLAM
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-0238
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-3600
Practice Address - Fax:336-716-6622
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC279599163W00000X
NC5015063363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse