Healthcare Provider Details

I. General information

NPI: 1497564249
Provider Name (Legal Business Name): MAEVE SHEA IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 GRANITE ST APT 4
PORTLAND ME
04102-2833
US

IV. Provider business mailing address

25 GRANITE ST APT 4
PORTLAND ME
04102-2833
US

V. Phone/Fax

Practice location:
  • Phone: 781-264-7394
  • Fax:
Mailing address:
  • Phone: 781-264-7394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-317152
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: