Healthcare Provider Details

I. General information

NPI: 1871371336
Provider Name (Legal Business Name): KACEY LAINE HECKATHORN RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9925 MORGANTOWN RD
NEWBURG MD
20664-2318
US

IV. Provider business mailing address

9925 MORGANTOWN RD
NEWBURG MD
20664-2318
US

V. Phone/Fax

Practice location:
  • Phone: 240-320-4202
  • Fax:
Mailing address:
  • Phone: 240-320-4202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-309407
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR232561
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: