Healthcare Provider Details

I. General information

NPI: 1972046928
Provider Name (Legal Business Name): BERNADETTE FISH RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 11/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 N 400 W
OREM UT
84057-1913
US

IV. Provider business mailing address

PO BOX 254
SALEM UT
84653-0254
US

V. Phone/Fax

Practice location:
  • Phone: 801-830-0109
  • Fax:
Mailing address:
  • Phone: 801-830-0109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number3241653102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: