=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407621014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSAY CORLEW RD, IBCLC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2023
-----------------------------------------------------
Last Update Date | 11/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 760 MCINTYRE ST
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42101-7456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-405-6496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 760 MCINTYRE ST
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42101-7456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-405-6496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174N00000X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Non-RN)
-----------------------------------------------------
License Number | L-312003
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 86292589
-----------------------------------------------------
License Number State |
-----------------------------------------------------