Healthcare Provider Details

I. General information

NPI: 1164238481
Provider Name (Legal Business Name): RONNA WADDELL RN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10450 SHAKER DR STE 108
COLUMBIA MD
21046-2347
US

IV. Provider business mailing address

6326 RAINPRINT ROW
COLUMBIA MD
21045-4207
US

V. Phone/Fax

Practice location:
  • Phone: 443-227-5862
  • Fax:
Mailing address:
  • Phone: 919-360-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-316807
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: