Provider Demographics
NPI:1255685939
Name:KELLEY, KRISTIN (RN IBCLC)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28706 E 81ST ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-5731
Mailing Address - Country:US
Mailing Address - Phone:918-606-2077
Mailing Address - Fax:
Practice Address - Street 1:28706 E 81ST ST S
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-5731
Practice Address - Country:US
Practice Address - Phone:918-606-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK82892163W00000X
ZZ11290981174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No174N00000XOther Service ProvidersLactation Consultant, Non-RN