Healthcare Provider Details

I. General information

NPI: 1467859058
Provider Name (Legal Business Name): LAURA MARIE MCCARTHY RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12103 GREENWAY CT APT. 101
FAIRFAX VA
22033-2564
US

IV. Provider business mailing address

12103 GREENWAY CT APT. 101
FAIRFAX VA
22033-2564
US

V. Phone/Fax

Practice location:
  • Phone: 571-722-6450
  • Fax:
Mailing address:
  • Phone: 571-722-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001226381
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-49236
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: