Healthcare Provider Details

I. General information

NPI: 1922345685
Provider Name (Legal Business Name): MARIANNE KMAK RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2013
Last Update Date: 01/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 S QUEBEC ST A-12
CENTENNIAL CO
80112-4411
US

IV. Provider business mailing address

7431 S IVY WAY
CENTENNIAL CO
80112-1509
US

V. Phone/Fax

Practice location:
  • Phone: 303-741-2550
  • Fax: 720-230-4898
Mailing address:
  • Phone: 720-219-2994
  • Fax: 720-230-4898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number0091589
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: