Healthcare Provider Details

I. General information

NPI: 1073292108
Provider Name (Legal Business Name): ERIN KACZMAREK MATTINGLY IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 PEMBROOKE DR
MADISON MS
39110-8638
US

IV. Provider business mailing address

415 PEMBROOKE DR
MADISON MS
39110-8638
US

V. Phone/Fax

Practice location:
  • Phone: 910-581-0800
  • Fax:
Mailing address:
  • Phone: 910-581-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: