Healthcare Provider Details

I. General information

NPI: 1801427927
Provider Name (Legal Business Name): CENTRAL CAROLINA LACTATION CONSULTANT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5374 TIMBER TRL
RANDLEMAN NC
27317-8293
US

IV. Provider business mailing address

5374 TIMBER TRL
RANDLEMAN NC
27317-8293
US

V. Phone/Fax

Practice location:
  • Phone: 336-633-9433
  • Fax:
Mailing address:
  • Phone: 336-633-9433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JANA SHOPTAW
Title or Position: LACTATION CONSULTANT
Credential: BSN RN IBCLC
Phone: 336-493-8829