Healthcare Provider Details

I. General information

NPI: 1356255459
Provider Name (Legal Business Name): JOSELYNNE DIANA WHITESIDE IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SHILOH RD NW STE 1630
KENNESAW GA
30144-7168
US

IV. Provider business mailing address

4636 BREAKWATER WAY
MARIETTA GA
30066-6710
US

V. Phone/Fax

Practice location:
  • Phone: 470-256-5777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-32242
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: