Provider Demographics
NPI:1598296154
Name:LANGE, KELLI L (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:L
Last Name:LANGE
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 1:17482 AMAGANSET WAY
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2510
Mailing Address - Country:US
Mailing Address - Phone:714-292-1398
Mailing Address - Fax:
Practice Address - Street 1:17482 AMAGANSET WAY
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2510
Practice Address - Country:US
Practice Address - Phone:714-292-1398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA545992163W00000X
CAL-85403163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse