MEDICARE: THE BREAST NURSE LLC

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)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043057532	OTHER	ID	NPI

General Provider Information

NPI Number	:	1154154920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BREAST NURSE LLC

Provider Business Mailing Address
First Line	:	1834 BROADVIEW DR
Second Line	:
City	:	LEWISTON
State	:	ID
Zip	:	83501-3962
Country	:	US
Telephone Number	:	208-305-1732
Fax Number	:

Provider Business Practice Location Address
First Line	:	1834 BROADVIEW DR
Second Line	:
City	:	LEWISTON
State	:	ID
Zip	:	83501-3962
Country	:	US
Telephone Number	:	208-305-1732
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	K'LEE LYNAE KASPER
Credential	:	BSN, RN, IBCLC
Telephone Number	:	208-305-1732

Provider Enumeration Date	:	08/26/2024
Last Update Date	:	08/26/2024

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Directions to “THE BREAST NURSE LLC ” Practice Location

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