Healthcare Provider Details

I. General information

NPI: 1629520523
Provider Name (Legal Business Name): MARY WELLS IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

682 FISKE RD
BARTON VT
05822-9395
US

IV. Provider business mailing address

682 FISKE RD
BARTON VT
05822-9395
US

V. Phone/Fax

Practice location:
  • Phone: 802-355-0706
  • Fax:
Mailing address:
  • Phone: 802-355-0706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number026.0017291
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: