Healthcare Provider Details

I. General information

NPI: 1679113021
Provider Name (Legal Business Name): LACTATION CONSUTANT ON THE GO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 VISTA DEL REY DR
VADO NM
88072-7236
US

IV. Provider business mailing address

220 VISTA DEL REY DR
VADO NM
88072-7236
US

V. Phone/Fax

Practice location:
  • Phone: 575-233-3240
  • Fax:
Mailing address:
  • Phone: 575-233-3240
  • 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: DEBORAH STAFFORD
Title or Position: CEO
Credential: RN, IBCLC
Phone: 575-233-3240