Healthcare Provider Details

I. General information

NPI: 1306662481
Provider Name (Legal Business Name): KELLIE JO FATEMIAN RN, IBCLBC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2024
Last Update Date: 11/23/2024
Certification Date: 11/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 N MACARTHUR BLVD
IRVING TX
75061-2220
US

IV. Provider business mailing address

11427 PARK CENTRAL PL
DALLAS TX
75230-3357
US

V. Phone/Fax

Practice location:
  • Phone: 214-606-5352
  • Fax:
Mailing address:
  • Phone: 214-606-5352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-157278
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: