Healthcare Provider Details

I. General information

NPI: 1073130209
Provider Name (Legal Business Name): ASHLEY LAURA LUCAS RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 07/03/2020
Certification Date: 07/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5879 CROOKED CREEK DR
OOLTEWAH TN
37363-6571
US

IV. Provider business mailing address

5879 CROOKED CREEK DR
OOLTEWAH TN
37363-6571
US

V. Phone/Fax

Practice location:
  • Phone: 423-619-3622
  • Fax:
Mailing address:
  • Phone: 423-619-3622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN0000163787
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: