Healthcare Provider Details

I. General information

NPI: 1679368815
Provider Name (Legal Business Name): JANE ANN FOGDALL RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 44TH AVE SW STE 101
SEATTLE WA
98116-4467
US

IV. Provider business mailing address

3722 SW TRENTON ST
SEATTLE WA
98126-3643
US

V. Phone/Fax

Practice location:
  • Phone: 206-763-2733
  • Fax: 206-763-2122
Mailing address:
  • Phone: 206-777-5532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-15451
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00129803
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: