Healthcare Provider Details

I. General information

NPI: 1598163529
Provider Name (Legal Business Name): LORI SHAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORI REBMAN IBCLC

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 SEMINOLE RD
JACKSONVILLE FL
32205-8635
US

IV. Provider business mailing address

1616 SEMINOLE RD
JACKSONVILLE FL
32205-8635
US

V. Phone/Fax

Practice location:
  • Phone: 904-485-0861
  • Fax:
Mailing address:
  • Phone: 904-485-0861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-60764
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: