Healthcare Provider Details

I. General information

NPI: 1104255991
Provider Name (Legal Business Name): ASHLEY TREADWELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 11/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 PRIMROSE DR
LA MESA CA
91942-4032
US

IV. Provider business mailing address

6325 PRIMROSE DR
LA MESA CA
91942-4032
US

V. Phone/Fax

Practice location:
  • Phone: 917-744-3657
  • Fax:
Mailing address:
  • Phone: 917-744-3657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-50277
License Number StateCA

VIII. Authorized Official

Name: ASHLEY TODD TREADWELL
Title or Position: LACTATION CONSULTANT
Credential: IBCLC
Phone: 917-744-3657