Healthcare Provider Details

I. General information

NPI: 1629846159
Provider Name (Legal Business Name): MACEY BLAKE GEROLEMON IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7345 INTERNATIONAL PL # 1097345
LAKEWOOD RANCH FL
34240-8467
US

IV. Provider business mailing address

3583 SUGAR TREE PL
DURHAM NC
27713-1376
US

V. Phone/Fax

Practice location:
  • Phone: 941-254-2502
  • Fax:
Mailing address:
  • Phone: 919-349-3145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: