Healthcare Provider Details

I. General information

NPI: 1023470283
Provider Name (Legal Business Name): AVIVA LEVY FAUST IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LAS MANANITAS ST
SANTA FE NM
87501-1546
US

IV. Provider business mailing address

200 LAS MANANITAS ST
SANTA FE NM
87501-1546
US

V. Phone/Fax

Practice location:
  • Phone: 505-919-9626
  • Fax:
Mailing address:
  • Phone: 505-919-9626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number10964013
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: