Healthcare Provider Details

I. General information

NPI: 1083576003
Provider Name (Legal Business Name): CARLY WELLS RD & IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2025
Last Update Date: 11/28/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 E. BASELINE RD. #130
GILBERT AZ
85234
US

IV. Provider business mailing address

2451 E. BASELINE RD. #130
GILBERT AZ
85234
US

V. Phone/Fax

Practice location:
  • Phone: 480-626-6515
  • Fax: 480-507-2218
Mailing address:
  • Phone: 480-626-6515
  • Fax: 480-507-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-313583
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1062383
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: