Healthcare Provider Details

I. General information

NPI: 1386908366
Provider Name (Legal Business Name): KATHLEEN KENEALY STAHL RN,IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 HAMPTON RD
ANNAPOLIS MD
21409-4833
US

IV. Provider business mailing address

1174 HAMPTON ROAD
ANNAPOLIS MD
21409-4833
US

V. Phone/Fax

Practice location:
  • Phone: 443-458-8285
  • Fax:
Mailing address:
  • Phone: 443-458-8285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR161159
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: