Healthcare Provider Details

I. General information

NPI: 1518821586
Provider Name (Legal Business Name): AUTUMN ROSE WAHL IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN ROSE BOXALL IBCLC

II. Dates (important events)

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

III. Provider practice location address

260 E 200 N
PROVO UT
84606-3180
US

IV. Provider business mailing address

260 E 200 N
PROVO UT
84606-3180
US

V. Phone/Fax

Practice location:
  • Phone: 801-786-9613
  • Fax:
Mailing address:
  • Phone: 801-786-9613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: