Healthcare Provider Details

I. General information

NPI: 1730862707
Provider Name (Legal Business Name): KELLI LAVALLEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAE WINTER

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 PHENIX AVE
WEST WARWICK RI
02893-4328
US

IV. Provider business mailing address

83 PHENIX AVE
WEST WARWICK RI
02893-4328
US

V. Phone/Fax

Practice location:
  • Phone: 401-558-8008
  • Fax:
Mailing address:
  • Phone: 401-558-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: