Healthcare Provider Details

I. General information

NPI: 1366933368
Provider Name (Legal Business Name): HEIDI CREIGHTON RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 DUCK PLAIN RD
PLYMOUTH MA
02360-4522
US

IV. Provider business mailing address

39 DUCK PLAIN RD
PLYMOUTH MA
02360-4522
US

V. Phone/Fax

Practice location:
  • Phone: 617-922-2792
  • Fax:
Mailing address:
  • Phone: 617-922-2792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-120367
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: