Provider Demographics
NPI:1912721317
Name:MCBRIDE, KELLY (BSN, RN, IBCLC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:BSN, RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 WOODCHURCH LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5039
Mailing Address - Country:US
Mailing Address - Phone:904-612-3109
Mailing Address - Fax:
Practice Address - Street 1:17473 ASHCOMB WAY
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-6517
Practice Address - Country:US
Practice Address - Phone:813-291-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL-46975163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty