Healthcare Provider Details

I. General information

NPI: 1356760391
Provider Name (Legal Business Name): ANDREA K ACKERSON RD IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 W FOUNTAIN ST # 115
PROVIDENCE RI
02903-3515
US

IV. Provider business mailing address

171 FORGE RD
NORTH KINGSTOWN RI
02852-1007
US

V. Phone/Fax

Practice location:
  • Phone: 401-203-7248
  • Fax:
Mailing address:
  • Phone: 518-527-3213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number928270
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL56279
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: