MEDICARE: MS. GWENAN WILBUR 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)	041332219	IL

General Provider Information

NPI Number	:	1235401563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GWENAN WILBUR RN, IBCLC

Provider Business Mailing Address
First Line	:	6647 N TALMAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-5008
Country	:	US
Telephone Number	:	773-465-2766
Fax Number	:

Provider Business Practice Location Address
First Line	:	6647 N TALMAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-5008
Country	:	US
Telephone Number	:	773-465-2766
Fax Number	:

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

Provider Enumeration Date	:	02/01/2012
Last Update Date	:	02/01/2012

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