Healthcare Provider Details

I. General information

NPI: 1124447784
Provider Name (Legal Business Name): MODERN MAMA LACTATION CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 MEBANE LN
DURHAM NC
27703-7986
US

IV. Provider business mailing address

2807 MEBANE LN
DURHAM NC
27703-7986
US

V. Phone/Fax

Practice location:
  • Phone: 919-413-1782
  • Fax:
Mailing address:
  • Phone: 919-413-1782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-32748
License Number StateNC

VIII. Authorized Official

Name: MRS. JENNIFER LYNN MAJORS
Title or Position: REGISTERED LACTATION CONSULTANT
Credential: RN, IBCLC
Phone: 919-413-1782