Healthcare Provider Details

I. General information

NPI: 1275323602
Provider Name (Legal Business Name): LISA KAY MAIZE IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 05/08/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24894 RAVINE CT # 2204
FARMINGTON HILLS MI
48335-2432
US

IV. Provider business mailing address

24894 RAVINE CT # 2204
FARMINGTON HILLS MI
48335-2432
US

V. Phone/Fax

Practice location:
  • Phone: 407-791-3455
  • Fax:
Mailing address:
  • Phone: 407-791-3455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-145779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: