Healthcare Provider Details

I. General information

NPI: 1598420325
Provider Name (Legal Business Name): MICHELLE R REITZ RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2021
Last Update Date: 11/06/2021
Certification Date: 11/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 KAYLA LN
HANOVER MN
55341-4504
US

IV. Provider business mailing address

558 KAYLA LN
HANOVER MN
55341-4504
US

V. Phone/Fax

Practice location:
  • Phone: 612-709-3681
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number1645273
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: