=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285395244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERRO DEBLASSIE RN, BSN, IBCLC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2022
-----------------------------------------------------
Last Update Date | 01/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4764 E BONANZA RD
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-7453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-544-6592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4764 E BONANZA RD
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-7453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-544-6592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number | 261166
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------