Healthcare Provider Details

I. General information

NPI: 1295030690
Provider Name (Legal Business Name): LOUISE MARIE PETERSON RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 4TH AVE
SEATTLE WA
98121-2308
US

IV. Provider business mailing address

1959 NE PACIFIC ST BOX 356079
SEATTLE WA
98195-3208
US

V. Phone/Fax

Practice location:
  • Phone: 206-263-9282
  • Fax:
Mailing address:
  • Phone: 206-598-4628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN 00111274
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: