Healthcare Provider Details

I. General information

NPI: 1659008464
Provider Name (Legal Business Name): GRACE HULTQUIST IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10775 MCKINLEY HWY STE C
OSCEOLA IN
46561-9164
US

IV. Provider business mailing address

10775 MCKINLEY HWY STE C
OSCEOLA IN
46561-9164
US

V. Phone/Fax

Practice location:
  • Phone: 574-334-7294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-315011
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: