Healthcare Provider Details

I. General information

NPI: 1780123885
Provider Name (Legal Business Name): CORINNE GEORGETTE-MARIE CARLSON RN - IBCHLC (LACTATI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 WHITE OAK DRIVE
PENSACOLA FL
32503
US

IV. Provider business mailing address

6809 WHITE OAK DRIVE
PENSACOLA FL
32503
US

V. Phone/Fax

Practice location:
  • Phone: 850-776-9204
  • Fax:
Mailing address:
  • Phone: 850-776-9204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN9173931
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: