Healthcare Provider Details

I. General information

NPI: 1285451047
Provider Name (Legal Business Name): DEIDRA WASHINGTON IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5149 STERLING MANOR DR
TAMPA FL
33647-2026
US

IV. Provider business mailing address

5149 STERLING MANOR DR
TAMPA FL
33647-2026
US

V. Phone/Fax

Practice location:
  • Phone: 813-753-1499
  • Fax:
Mailing address:
  • Phone: 813-753-1499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-303479
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: