MEDICARE: ANEESA MALOUF BEUTLER 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)	L-86712	ID
2	174N00000X	Lactation Consultant (Non-RN)	L-86712	ID

General Provider Information

NPI Number	:	1669837829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANEESA MALOUF BEUTLER R.N., IBCLC

Provider Business Mailing Address
First Line	:	74 S HIGHWAY 36
Second Line	:
City	:	WESTON
State	:	ID
Zip	:	83286-5000
Country	:	US
Telephone Number	:	435-554-1098
Fax Number	:

Provider Business Practice Location Address
First Line	:	74 S HIGHWAY 36
Second Line	:
City	:	WESTON
State	:	ID
Zip	:	83286-5000
Country	:	US
Telephone Number	:	435-554-1098
Fax Number	:

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

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	12/15/2015

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