Healthcare Provider Details

I. General information

NPI: 1154247021
Provider Name (Legal Business Name): MADISON SMITH BSN, RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 W 4925 S
RIVERDALE UT
84405-6313
US

IV. Provider business mailing address

577 W 4925 S
RIVERDALE UT
84405-6313
US

V. Phone/Fax

Practice location:
  • Phone: 801-695-8172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-323173
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: