Healthcare Provider Details

I. General information

NPI: 1063715084
Provider Name (Legal Business Name): WINIFRED GLORY BELZONIA BURTON IBCLC, NAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TANISHA RENEE GRICE

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 LAKE ST UNIT 1044
OAK PARK IL
60301-1301
US

IV. Provider business mailing address

805 LAKE ST UNIT 1044
OAK PARK IL
60301-1301
US

V. Phone/Fax

Practice location:
  • Phone: 313-327-2325
  • Fax:
Mailing address:
  • Phone: 313-327-2325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number11099970
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: