Healthcare Provider Details

I. General information

NPI: 1205658945
Provider Name (Legal Business Name): WILD MILK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4946 E SAWMILL WAY
BOISE ID
83716-6700
US

IV. Provider business mailing address

10960 W THREADGRASS ST
STAR ID
83669-6334
US

V. Phone/Fax

Practice location:
  • Phone: 209-765-2399
  • Fax:
Mailing address:
  • Phone: 310-989-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MAUREEN LEGASPI
Title or Position: OWNER
Credential: RN, IBCLC
Phone: 310-989-4820