Healthcare Provider Details

I. General information

NPI: 1013676394
Provider Name (Legal Business Name): SOAK LACTATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5426 MIDVALE DR UNIT A
ROCKFORD IL
61108-2326
US

IV. Provider business mailing address

5426 MIDVALE DR UNIT A
ROCKFORD IL
61108-2326
US

V. Phone/Fax

Practice location:
  • Phone: 815-540-3613
  • Fax:
Mailing address:
  • Phone: 815-540-3613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name: NICOLE SANTANA
Title or Position: OWNER
Credential: RN, IBCLC, CLE, CBE
Phone: 815-540-3613