Provider Demographics
NPI:1407621014
Name:CORLEW, KELSAY (RD, IBCLC)
Entity Type:Individual
Prefix:
First Name:KELSAY
Middle Name:
Last Name:CORLEW
Suffix:
Gender:F
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 MCINTYRE ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-7456
Mailing Address - Country:US
Mailing Address - Phone:270-405-6496
Mailing Address - Fax:
Practice Address - Street 1:760 MCINTYRE ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-7456
Practice Address - Country:US
Practice Address - Phone:270-405-6496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-24
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-312003174N00000X
86292589133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN