Healthcare Provider Details

I. General information

NPI: 1457111668
Provider Name (Legal Business Name): LILLIANNE CHRISTINE MOODY CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2024
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4051 N SUPERSTITION CT
PRESCOTT VALLEY AZ
86314-7630
US

IV. Provider business mailing address

4051 N SUPERSTITION CT
PRESCOTT VALLEY AZ
86314-7630
US

V. Phone/Fax

Practice location:
  • Phone: 928-830-1642
  • Fax:
Mailing address:
  • Phone: 928-830-1642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number348436
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: