Healthcare Provider Details

I. General information

NPI: 1235401563
Provider Name (Legal Business Name): GWENAN WILBUR RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6647 N TALMAN AVE
CHICAGO IL
60645-5008
US

IV. Provider business mailing address

6647 N TALMAN AVE
CHICAGO IL
60645-5008
US

V. Phone/Fax

Practice location:
  • Phone: 773-465-2766
  • Fax:
Mailing address:
  • Phone: 773-465-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number041332219
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: