Provider Demographics
NPI:1952754186
Name:VREDENBURG, KELLY LEI (CLC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEI
Last Name:VREDENBURG
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 HARLAND DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-9209
Mailing Address - Country:US
Mailing Address - Phone:218-760-5225
Mailing Address - Fax:
Practice Address - Street 1:520 HARLAND DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-9209
Practice Address - Country:US
Practice Address - Phone:218-760-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-23
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN241479174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN