Healthcare Provider Details

I. General information

NPI: 1114740644
Provider Name (Legal Business Name): EMILY NICOLE BURKHEAD IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
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

7479 COLLINS MEADE WAY
ALEXANDRIA VA
22315-5254
US

V. Phone/Fax

Practice location:
  • Phone: 202-293-5182
  • Fax:
Mailing address:
  • Phone: 443-752-6261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-302713
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: