Healthcare Provider Details

I. General information

NPI: 1467739359
Provider Name (Legal Business Name): SHAMMAH KRIS DELASSE IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 N LEWIS PL
TULSA OK
74110-2125
US

IV. Provider business mailing address

2211 N LEWIS PL
TULSA OK
74110-2125
US

V. Phone/Fax

Practice location:
  • Phone: 918-902-9368
  • Fax:
Mailing address:
  • Phone: 918-902-9368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number11190051
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: