MEDICARE: KRISTIN MARIE PELLETIER IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WL0100X	Lactation Consultant (Registered Nurse)	085071	CT

General Provider Information

NPI Number	:	1104343045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN MARIE PELLETIER IBCLC

Provider Business Mailing Address
First Line	:	3 WINDSOR CT
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06032-1458
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2113 HIGHLAND RIDGE DR
Second Line	:
City	:	PHOENIX
State	:	MD
Zip	:	21131-1217
Country	:	US
Telephone Number	:	410-443-0022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2017
Last Update Date	:	08/22/2017

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