Healthcare Provider Details

I. General information

NPI: 1417783754
Provider Name (Legal Business Name): NOURISHING JUSTLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5108 ARCHCREST WAY
SACRAMENTO CA
95835-1641
US

IV. Provider business mailing address

5108 ARCHCREST WAY
SACRAMENTO CA
95835-1641
US

V. Phone/Fax

Practice location:
  • Phone: 916-572-4433
  • Fax:
Mailing address:
  • Phone: 916-572-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. KAVISA WOOD
Title or Position: CLINICAL DIRECTOR
Credential: IBCLC
Phone: 916-572-4433