Provider Demographics
NPI:1457765075
Name:KELLY, SUMMER GLYNN (RN, BSN, IBCLC, LCCE)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:GLYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC, LCCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 N NEENAH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-4018
Mailing Address - Country:US
Mailing Address - Phone:773-316-4017
Mailing Address - Fax:773-341-1597
Practice Address - Street 1:4828 N NEENAH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-4018
Practice Address - Country:US
Practice Address - Phone:773-316-4017
Practice Address - Fax:773-341-1597
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041348560163WL0100X, 163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn