Healthcare Provider Details

I. General information

NPI: 1760347306
Provider Name (Legal Business Name): CARRIE DISTEFANO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 SHERIDAN ST
ASHLAND OR
97520-1525
US

IV. Provider business mailing address

425 SHERIDAN ST
ASHLAND OR
97520-1525
US

V. Phone/Fax

Practice location:
  • Phone: 458-225-0247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: CARRIE DISTEFANO
Title or Position: OWNER
Credential: IBCLC
Phone: 458-225-0247