Healthcare Provider Details

I. General information

NPI: 1053142398
Provider Name (Legal Business Name): LAURA L KELSEY RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 BUGGER HOLLOW RD
FAYETTEVILLE TN
37334-6863
US

IV. Provider business mailing address

65 BUGGER HOLLOW RD
FAYETTEVILLE TN
37334-6863
US

V. Phone/Fax

Practice location:
  • Phone: 320-703-8214
  • Fax:
Mailing address:
  • Phone: 320-703-8214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number250884
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number250884
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: