Provider Demographics
NPI:1477165835
Name:MACMILLAN, KELLY (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MACMILLAN
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 1:44 BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1690
Mailing Address - Country:US
Mailing Address - Phone:585-206-1189
Mailing Address - Fax:
Practice Address - Street 1:44 BRISTOL ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1690
Practice Address - Country:US
Practice Address - Phone:585-206-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY674991-1163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
15678017OtherCAQH