Healthcare Provider Details

I. General information

NPI: 1669337978
Provider Name (Legal Business Name): SIERRA MATHOS IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 CROWFOOT LN
EVERGREEN CO
80439-4029
US

IV. Provider business mailing address

8200 CROWFOOT LN
EVERGREEN CO
80439-4029
US

V. Phone/Fax

Practice location:
  • Phone: 785-787-8240
  • Fax:
Mailing address:
  • Phone: 785-787-8240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-320167
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: