Healthcare Provider Details

I. General information

NPI: 1750818126
Provider Name (Legal Business Name): CREATIVE LACTATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17376 TEDLER CIR
ROUND HILL VA
20141-2633
US

IV. Provider business mailing address

17376 TEDLER CIR
ROUND HILL VA
20141-2633
US

V. Phone/Fax

Practice location:
  • Phone: 540-466-1797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JESSICA SYPOLT
Title or Position: OWNER
Credential: IBCLC, RLC
Phone: 540-466-1797