Healthcare Provider Details

I. General information

NPI: 1164996336
Provider Name (Legal Business Name): MAHEALANI KIM BUCKLER RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAHEALANI KIM CROSSLEY

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8325 UNIVERSITY AVE
LA MESA CA
91942-9322
US

IV. Provider business mailing address

8781 TOMMY DR
SAN DIEGO CA
92119-2013
US

V. Phone/Fax

Practice location:
  • Phone: 619-343-2502
  • Fax:
Mailing address:
  • Phone: 303-859-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number782243
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: