Healthcare Provider Details

I. General information

NPI: 1760821102
Provider Name (Legal Business Name): SARA GENEVIEVE PENNINGTON RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 PARKMAN WOOD RD
PUTNEY VT
05346
US

IV. Provider business mailing address

134 PARKMAN WOOD RD
PUTNEY VT
05346
US

V. Phone/Fax

Practice location:
  • Phone: 802-380-8952
  • Fax:
Mailing address:
  • Phone: 802-380-8952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number026-0029824
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: