=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275397929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY SUSANNE HILLERY RN, IBCLC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2024
-----------------------------------------------------
Last Update Date | 02/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2667 CAMINO DEL RIO S STE 201
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-204-8518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232 GLEN ARBOR DR
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-204-8518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number | L-305210
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number | 732151
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------