Healthcare Provider Details

I. General information

NPI: 1598015364
Provider Name (Legal Business Name): JAM (JOYCE) GOURLEY BS, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SUNNYBROOK RD
RALEIGH NC
27610-1808
US

IV. Provider business mailing address

10 SUNNYBROOK RD
RALEIGH NC
27610-1808
US

V. Phone/Fax

Practice location:
  • Phone: 919-612-8327
  • Fax: 919-212-7558
Mailing address:
  • Phone: 919-612-8327
  • Fax: 919-212-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: