Healthcare Provider Details

I. General information

NPI: 1568680312
Provider Name (Legal Business Name): ELIZABETH KELLY MS, RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 02/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4925 N LEAVITT ST
CHICAGO IL
60625-1308
US

IV. Provider business mailing address

4925 N LEAVITT ST
CHICAGO IL
60625-1308
US

V. Phone/Fax

Practice location:
  • Phone: 312-380-9638
  • Fax:
Mailing address:
  • Phone: 312-380-9638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number041.389385
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: