Healthcare Provider Details

I. General information

NPI: 1598169302
Provider Name (Legal Business Name): SUSAM ANN MARTIN RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 WILLOW ST
PELHAM NH
03076-3128
US

IV. Provider business mailing address

26 WILLOW ST
PELHAM NH
03076-3128
US

V. Phone/Fax

Practice location:
  • Phone: 978-758-2325
  • Fax:
Mailing address:
  • Phone: 978-758-2325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN164582
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number10117450
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: