Healthcare Provider Details

I. General information

NPI: 1285511683
Provider Name (Legal Business Name): IMANI SADE MALLARD RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 19TH ST NW STE 150
WASHINGTON DC
20036-6103
US

IV. Provider business mailing address

10945 PRICE MANOR WAY
LAUREL MD
20723-6036
US

V. Phone/Fax

Practice location:
  • Phone: 202-293-5182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberR254502
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WN0003X
TaxonomyLow-Risk Neonatal Registered Nurse
License NumberRN500016940
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-319151
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: