Healthcare Provider Details

I. General information

NPI: 1598587388
Provider Name (Legal Business Name): LUCIA ELIZABETH FONSECA IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3118 N 22ND ST
PHOENIX AZ
85016-7348
US

IV. Provider business mailing address

3118 N 22ND ST
PHOENIX AZ
85016-7348
US

V. Phone/Fax

Practice location:
  • Phone: 602-910-0571
  • Fax:
Mailing address:
  • Phone: 602-910-0571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN193533
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: