Healthcare Provider Details

I. General information

NPI: 1497474936
Provider Name (Legal Business Name): KELLY ANN MURPHY ANDRUK IBCLC, LCCE, RYT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GERARD ST
MANCHESTER CT
06040-4414
US

IV. Provider business mailing address

2 GERARD ST
MANCHESTER CT
06040-4414
US

V. Phone/Fax

Practice location:
  • Phone: 860-978-2066
  • Fax:
Mailing address:
  • Phone: 860-978-2066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-301433
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: