Provider Demographics
NPI:1073172367
Name:BRIEN, KELLI NICOLE (CD(DONA) LCCE, CLS)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:NICOLE
Last Name:BRIEN
Suffix:
Gender:F
Credentials:CD(DONA) LCCE, CLS
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 2648
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46680-2648
Mailing Address - Country:US
Mailing Address - Phone:574-383-1743
Mailing Address - Fax:
Practice Address - Street 1:115 E WOODSIDE ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-1113
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 174H00000X, 174N00000X, 261QB0400X, 261QF0050X, 261QP0905X
IN374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker
No174H00000XOther Service ProvidersHealth Educator
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local