Healthcare Provider Details

I. General information

NPI: 1497636823
Provider Name (Legal Business Name): SHANNON BENTLEY CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 E STATE ST
ITHACA NY
14850-4318
US

IV. Provider business mailing address

1233 S GILBERT RD APT 6308
GILBERT AZ
85296-4902
US

V. Phone/Fax

Practice location:
  • Phone: 888-991-6772
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberALPP-362424
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: