=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629868716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILKY WAY BREASTFEEDING MEDICINE OF CT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2025
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 NEW LONDON TPKE STE 301
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-4256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-700-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 RIDGEWOOD DR
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-700-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. KATHLEEN ANN MARINELLI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 860-700-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------