Healthcare Provider Details

I. General information

NPI: 1104625060
Provider Name (Legal Business Name): ALYSSA DENISE HUMPHRIES RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2744 MILLWOOD AVE
COLUMBIA SC
29205-1221
US

IV. Provider business mailing address

668 CARRIAGE LAKE DR
LEXINGTON SC
29072-7513
US

V. Phone/Fax

Practice location:
  • Phone: 803-879-5998
  • Fax:
Mailing address:
  • Phone: 803-528-6534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-135187
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: