MEDICARE: JENNIFER DAVIS R.N., 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)	026.0025071	VT
2	163WL0100X	Lactation Consultant (Registered Nurse)	069122-21	NH

General Provider Information

NPI Number	:	1164842399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DAVIS R.N., IBCLC

Provider Business Mailing Address
First Line	:	12 PROSPECT AVE
Second Line	:
City	:	RANDOLPH
State	:	VT
Zip	:	05060-1359
Country	:	US
Telephone Number	:	802-728-4105
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 PROSPECT AVE
Second Line	:
City	:	RANDOLPH
State	:	VT
Zip	:	05060-1359
Country	:	US
Telephone Number	:	802-728-4105
Fax Number	:

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

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	04/28/2014

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