Healthcare Provider Details

I. General information

NPI: 1104424365
Provider Name (Legal Business Name): PROLACTIN LIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2020
Last Update Date: 10/10/2020
Certification Date: 10/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15012 NOTLEY RD
SILVER SPRING MD
20905-7437
US

IV. Provider business mailing address

15012 NOTLEY RD
SILVER SPRING MD
20905-7437
US

V. Phone/Fax

Practice location:
  • Phone: 240-360-1205
  • Fax:
Mailing address:
  • Phone: 240-360-1205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARIANNE WYSONG
Title or Position: OWNER
Credential: RN, IBCLC
Phone: 240-360-1205