Provider Demographics
NPI:1871017483
Name:CANADY, KELLI (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:CANADY
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 1:1327 ROBESON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5531
Mailing Address - Country:US
Mailing Address - Phone:910-486-5437
Mailing Address - Fax:
Practice Address - Street 1:1327 ROBESON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5531
Practice Address - Country:US
Practice Address - Phone:910-486-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC286991163W00000X
NCL42213163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
L-42213OtherIBCLC