Healthcare Provider Details

I. General information

NPI: 1265842546
Provider Name (Legal Business Name): JOHANNA ELISABETH IWASZKOWIEC IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 WATERWHEEL PL
SAINT CHARLES MO
63301-2433
US

IV. Provider business mailing address

3104 WATERWHEEL PL
SAINT CHARLES MO
63301-2433
US

V. Phone/Fax

Practice location:
  • Phone: 636-306-3410
  • Fax: 636-206-8193
Mailing address:
  • Phone: 636-486-6016
  • 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: