Healthcare Provider Details

I. General information

NPI: 1497003719
Provider Name (Legal Business Name): GENA KAY GRESHAM IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ZENA KAY INGRAM IBCLC

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8670 W CHEYENNE AVE SUITE 120
LAS VEGAS NV
89129-7456
US

IV. Provider business mailing address

8670 W CHEYENNE AVE SUITE 120
LAS VEGAS NV
89129-7456
US

V. Phone/Fax

Practice location:
  • Phone: 702-425-2791
  • Fax: 725-877-2701
Mailing address:
  • Phone: 702-425-2791
  • Fax: 725-877-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: