Healthcare Provider Details

I. General information

NPI: 1508511619
Provider Name (Legal Business Name): NATURAL NOURISH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20493 E 1200 RD
ALLENDALE IL
62410-2099
US

IV. Provider business mailing address

20493 E 1200 RD
ALLENDALE IL
62410-2099
US

V. Phone/Fax

Practice location:
  • Phone: 618-262-3622
  • Fax:
Mailing address:
  • Phone: 618-262-3622
  • 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: CHRISTINA MAYBERRY
Title or Position: IBCLC
Credential: RN
Phone: 618-262-3622