Healthcare Provider Details

I. General information

NPI: 1629576046
Provider Name (Legal Business Name): MEREDITH BROOKE MANCE CPM, LDM, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 NE 3RD ST STE 7
MCMINNVILLE OR
97128-6219
US

IV. Provider business mailing address

22205 WALLACE RD NW
SALEM OR
97304-9628
US

V. Phone/Fax

Practice location:
  • Phone: 503-495-3266
  • Fax: 971-545-7774
Mailing address:
  • Phone: 213-448-2355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-149934
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number99320
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberDEM-LD-10195740
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10051405
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: