Provider Demographics
NPI:1528543337
Name:RYAN, KELLY (IBCLC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 MICHAEL DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-4208
Mailing Address - Country:US
Mailing Address - Phone:650-867-6752
Mailing Address - Fax:
Practice Address - Street 1:3533 MICHAEL DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4208
Practice Address - Country:US
Practice Address - Phone:650-867-6752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-110775174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN