Provider Demographics
NPI:1447879895
Name:LEOPOLD, KELLY ANN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:LEOPOLD
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 1:8264 LYTLE TRAILS RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-9255
Mailing Address - Country:US
Mailing Address - Phone:937-673-1232
Mailing Address - Fax:
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0027080363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal