MEDICARE: MINDFUL LACTATION EDUCATION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	133N00000X	Nutritionist
2	2083C0008X	Clinical Informatics Physician
3	261QM3000X	Medically Fragile Infants and Children Day Care
4	390200000X	Student in an Organized Health Care Education/Training Program
5	174H00000X	Health Educator

General Provider Information

NPI Number	:	1679174148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL LACTATION EDUCATION, LLC

Provider Business Mailing Address
First Line	:	213 RUSSELL CT
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-2918
Country	:	US
Telephone Number	:	470-533-9119
Fax Number	:

Provider Business Practice Location Address
First Line	:	213 RUSSELL CT
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-2918
Country	:	US
Telephone Number	:	470-533-9119
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	JENNIFER MICHELLE FOSTER
Credential	:	CD, IBCLC, RLC
Telephone Number	:	470-533-9119

Provider Enumeration Date	:	11/02/2020
Last Update Date	:	11/02/2020

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