MEDICARE: LORI MANDUKE RN, NP, 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)	359159	CA

General Provider Information

NPI Number	:	1831557164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI MANDUKE RN, NP, IBCLC

Provider Business Mailing Address
First Line	:	6346 LANGHALL CT
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-4114
Country	:	US
Telephone Number	:	818-822-1919
Fax Number	:	818-991-7500

Provider Business Practice Location Address
First Line	:	6346 LANGHALL CT
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-4114
Country	:	US
Telephone Number	:	818-822-1919
Fax Number	:	818-991-7500

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

Provider Enumeration Date	:	02/01/2016
Last Update Date	:	02/01/2016

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