Healthcare Provider Details

I. General information

NPI: 1629834809
Provider Name (Legal Business Name): MARY O'DONNELL IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MURIFIELD DR
JACKSONVILLE NC
28540-9383
US

IV. Provider business mailing address

106 MURIFIELD DR
JACKSONVILLE NC
28540-9383
US

V. Phone/Fax

Practice location:
  • Phone: 618-558-0283
  • Fax:
Mailing address:
  • Phone: 618-558-0283
  • 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: