Healthcare Provider Details

I. General information

NPI: 1780400952
Provider Name (Legal Business Name): MAKAYLA V BOWNE IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3756 CAMELOT DR SE APT 1B
GRAND RAPIDS MI
49546-6030
US

IV. Provider business mailing address

3756 CAMELOT DR SE APT 1B
GRAND RAPIDS MI
49546-6030
US

V. Phone/Fax

Practice location:
  • Phone: 616-328-3518
  • Fax:
Mailing address:
  • Phone: 616-328-3518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: