Healthcare Provider Details

I. General information

NPI: 1457694101
Provider Name (Legal Business Name): M. PATRICIA JANICEK RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 PLAINFIELD RD STE C
WILLOWBROOK IL
60527-7601
US

IV. Provider business mailing address

6103 GRAND AVE
DOWNERS GROVE IL
60516-2003
US

V. Phone/Fax

Practice location:
  • Phone: 630-654-2229
  • Fax:
Mailing address:
  • Phone: 630-776-6975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number041196581
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: