=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245747914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILKY MAMA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2018
-----------------------------------------------------
Last Update Date | 04/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10722 ARROW RTE STE 104
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-886-4559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10722 ARROW RTE STE 104
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-886-4559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KRYSTAL N DUHANEY
-----------------------------------------------------
Credential | RN, BSN, IBCLC
-----------------------------------------------------
Telephone | 951-347-8730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174N00000X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Non-RN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number | 818893
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------