Healthcare Provider Details

I. General information

NPI: 1295087203
Provider Name (Legal Business Name): EILEEN KIM PETROCELLI IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EILEEN MACMULLEN

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 N WINDSONG DR 2ND FLOOR
PRESCOTT VALLEY AZ
86314-2255
US

IV. Provider business mailing address

1090 COMMERCE DR
PRESCOTT AZ
86305-3700
US

V. Phone/Fax

Practice location:
  • Phone: 928-583-1037
  • Fax: 928-771-3379
Mailing address:
  • Phone: 928-771-3121
  • Fax: 928-771-3369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number11132727
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: