Healthcare Provider Details

I. General information

NPI: 1710798285
Provider Name (Legal Business Name): COURTNEY MARIE WALLACE RN, PHN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COURTNEY MARIE HULTGEN

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 BARRY DR
VENTURA CA
93001-1495
US

IV. Provider business mailing address

363 BARRY DR
VENTURA CA
93001-1495
US

V. Phone/Fax

Practice location:
  • Phone: 805-798-1596
  • Fax:
Mailing address:
  • Phone: 805-798-1596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number821163
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: