Healthcare Provider Details

I. General information

NPI: 1912737586
Provider Name (Legal Business Name): JASMINE ALEXANDRIA ORTIN RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N 108TH PL STE 203
WAUWATOSA WI
53226-4253
US

IV. Provider business mailing address

157 WALTON AVE
WAUKESHA WI
53186-5903
US

V. Phone/Fax

Practice location:
  • Phone: 414-249-4420
  • Fax:
Mailing address:
  • Phone: 248-709-8339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number224190
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: