Provider Demographics
NPI:1275397929
Name:HILLERY, KELLY SUSANNE (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUSANNE
Last Name:HILLERY
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 1:232 GLEN ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-4319
Mailing Address - Country:US
Mailing Address - Phone:858-204-8518
Mailing Address - Fax:
Practice Address - Street 1:2667 CAMINO DEL RIO S STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3733
Practice Address - Country:US
Practice Address - Phone:858-204-8518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-305210163WL0100X
CA732151163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant