Healthcare Provider Details

I. General information

NPI: 1518421650
Provider Name (Legal Business Name): THE LACTATION CLINIC OF SOUTHEAST WISCONSIN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N 108TH PL STE 100
WAUWATOSA WI
53226-4253
US

IV. Provider business mailing address

530 N 108TH PL STE 100
WAUWATOSA WI
53226-4253
US

V. Phone/Fax

Practice location:
  • Phone: 414-628-7659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTEN LEE
Title or Position: DIRECTOR/PRESIDENT
Credential: DC, CLC
Phone: 414-628-7659