Healthcare Provider Details

I. General information

NPI: 1043039605
Provider Name (Legal Business Name): KIMBERLY KOURETCHIAN RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM KOURETCHIAN

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 W CARROLL AVE
CHICAGO IL
60612-2501
US

IV. Provider business mailing address

10185 MYSTIC FALLS DR
LAS VEGAS NV
89141-9039
US

V. Phone/Fax

Practice location:
  • Phone: 888-510-0059
  • Fax: 708-406-1629
Mailing address:
  • Phone: 206-708-3406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60593785
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-308290
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: