Provider Demographics
NPI:1740534247
Name:MISSET, KELLYN (ND, LAC)
Entity type:Individual
Prefix:
First Name:KELLYN
Middle Name:
Last Name:MISSET
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 MAIN ST STE 8B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:755 MAIN ST STE 8B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2830
Practice Address - Country:US
Practice Address - Phone:203-304-6043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000718171100000X
CT000616175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist