Healthcare Provider Details

I. General information

NPI: 1194101220
Provider Name (Legal Business Name): THIRD COAST LACTATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4925 N LEAVITT ST
CHICAGO IL
60625-1308
US

IV. Provider business mailing address

4925 N LEAVITT ST
CHICAGO IL
60625-1308
US

V. Phone/Fax

Practice location:
  • Phone: 312-380-9638
  • Fax:
Mailing address:
  • Phone: 312-380-9638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number041389385
License Number StateIL

VIII. Authorized Official

Name: ELIZABETH KELLY
Title or Position: LACTATION CONSULTANT & FOUNDER
Credential: MS, RN, IBCLC
Phone: 440-554-9321