Healthcare Provider Details

I. General information

NPI: 1093472441
Provider Name (Legal Business Name): GRETA ROSE COOK RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRETA ROSE THIBODEAU RN, IBCLC

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 11/19/2021
Certification Date: 11/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19820 VILLAGE OFFICE CT
BEND OR
97702-2947
US

IV. Provider business mailing address

19820 VILLAGE OFFICE CT
BEND OR
97702-2947
US

V. Phone/Fax

Practice location:
  • Phone: 907-723-7589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number201402427RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: