Healthcare Provider Details

I. General information

NPI: 1497961361
Provider Name (Legal Business Name): MELISSA LORI KOTLEN RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 02/09/2024
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E 96TH ST APT 18O
NEW YORK NY
10128-6209
US

IV. Provider business mailing address

175 E 96TH ST APT 18O
NEW YORK NY
10128-6209
US

V. Phone/Fax

Practice location:
  • Phone: 914-374-1632
  • Fax:
Mailing address:
  • Phone: 914-374-1632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number785274-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: