MEDICARE: ELIZABETH KELLY MS, RN, 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)	041.389385	IL

General Provider Information

NPI Number	:	1568680312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH KELLY MS, RN, IBCLC

Provider Business Mailing Address
First Line	:	4925 N LEAVITT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1308
Country	:	US
Telephone Number	:	312-380-9638
Fax Number	:

Provider Business Practice Location Address
First Line	:	4925 N LEAVITT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1308
Country	:	US
Telephone Number	:	312-380-9638
Fax Number	:

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	02/21/2016

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