Healthcare Provider Details

I. General information

NPI: 1871952507
Provider Name (Legal Business Name): WILLOW MERCHANT FNP, RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2016
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 W HILTON DR
BOULDER CREEK CA
95006-9207
US

IV. Provider business mailing address

343 W HILTON DR
BOULDER CREEK CA
95006-9207
US

V. Phone/Fax

Practice location:
  • Phone: 650-862-9336
  • Fax: 831-703-4773
Mailing address:
  • Phone: 650-862-9336
  • Fax: 831-703-4773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number545590
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: