Healthcare Provider Details

I. General information

NPI: 1184403743
Provider Name (Legal Business Name): STEPHANIE RODRIGUEZ-NINMAN RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 TILLARY ST APT 506
BROOKLYN NY
11201-2060
US

IV. Provider business mailing address

170 TILLARY ST APT 506
BROOKLYN NY
11201-2060
US

V. Phone/Fax

Practice location:
  • Phone: 612-310-0368
  • Fax:
Mailing address:
  • Phone: 612-310-0368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number659955
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number659955
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: