Provider Demographics
NPI:1306662481
Name:FATEMIAN, KELLIE JO (RN, IBCLBC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:JO
Last Name:FATEMIAN
Suffix:
Gender:F
Credentials:RN, IBCLBC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11427 PARK CENTRAL PL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-3357
Mailing Address - Country:US
Mailing Address - Phone:214-606-5352
Mailing Address - Fax:
Practice Address - Street 1:1901 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2220
Practice Address - Country:US
Practice Address - Phone:214-606-5352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-157278163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant