Healthcare Provider Details

I. General information

NPI: 1093112062
Provider Name (Legal Business Name): MUDIWAH ABASHALOM KADESHE RN,IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3029 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20032-2506
US

IV. Provider business mailing address

9109 FOWLER LN
LANHAM MD
20706-2451
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-4000
  • Fax:
Mailing address:
  • Phone: 202-669-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN55510
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: