Healthcare Provider Details

I. General information

NPI: 1992402861
Provider Name (Legal Business Name): MANIFESTING MAMA - BIRTH, LACTATION AND BEYOND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 TRESTMAN AVE
VIRGINIA BEACH VA
23464-1740
US

IV. Provider business mailing address

1000 TRESTMAN AVE
VIRGINIA BEACH VA
23464-1740
US

V. Phone/Fax

Practice location:
  • Phone: 757-567-2011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KIRSTEN O'NEILL
Title or Position: OWNER
Credential:
Phone: 757-567-2011