Healthcare Provider Details

I. General information

NPI: 1235467721
Provider Name (Legal Business Name): DEBRA SUE POLLESCH RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8707 W. NORTH AVE.
WAUWATOSA WI
53226-2723
US

IV. Provider business mailing address

2916 N 82 ST.
MILWAUKEE WI
53222-4816
US

V. Phone/Fax

Practice location:
  • Phone: 414-940-9262
  • Fax:
Mailing address:
  • Phone: 414-940-9262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number117057-030
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number10421156
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: