Healthcare Provider Details

I. General information

NPI: 1093345423
Provider Name (Legal Business Name): MARY CLARE OVALLE RD, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10290 N DEARING AVE
FRESNO CA
93730-4772
US

IV. Provider business mailing address

10290 N DEARING AVE
FRESNO CA
93730-4772
US

V. Phone/Fax

Practice location:
  • Phone: 559-304-0348
  • Fax:
Mailing address:
  • Phone: 559-304-0348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number655589
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-28731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: