Healthcare Provider Details

I. General information

NPI: 1811326564
Provider Name (Legal Business Name): GAIL DITTES RN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SHELLFLOWER RD
LEVITTOWN PA
19056-1707
US

IV. Provider business mailing address

17 SHELLFLOWER RD
LEVITTOWN PA
19056-1707
US

V. Phone/Fax

Practice location:
  • Phone: 267-241-1432
  • Fax:
Mailing address:
  • Phone: 267-879-5000
  • Fax: 267-393-4500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-46563
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: