Healthcare Provider Details

I. General information

NPI: 1063751576
Provider Name (Legal Business Name): GRETTA HALL BLYTHE RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRETTA JANE HALL RN

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5127 BOULWARE CT
CHARLOTTE NC
28277-9643
US

IV. Provider business mailing address

5127 BOULWARE CT
CHARLOTTE NC
28277-9643
US

V. Phone/Fax

Practice location:
  • Phone: 704-578-6323
  • Fax: 704-846-3421
Mailing address:
  • Phone: 704-578-6323
  • Fax: 704-846-3421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number70351
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: