=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780340414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LANDRY LACTATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2021
-----------------------------------------------------
Last Update Date | 11/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1708 CALIFORNIA AVE
-----------------------------------------------------
City | CHICKASHA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73018-6416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-303-0310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1708 CALIFORNIA AVE
-----------------------------------------------------
City | CHICKASHA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73018-6416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-303-0310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LACTATION CONSULTANT
-----------------------------------------------------
Name | BRIANNA LANDRY
-----------------------------------------------------
Credential | CBS
-----------------------------------------------------
Telephone | 580-303-0310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174N00000X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Non-RN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------