MEDICARE: NOURISH LACTATION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)

General Provider Information

NPI Number	:	1063361913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOURISH LACTATION LLC

Provider Business Mailing Address
First Line	:	6120 PAYNE AVE
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48126-2089
Country	:	US
Telephone Number	:	313-428-2706
Fax Number	:

Provider Business Practice Location Address
First Line	:	6120 PAYNE AVE
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48126-2089
Country	:	US
Telephone Number	:	313-428-2706
Fax Number	:

Authorized Official
Title or Position	:	LACTATION CONSULTANT
Name	:	MRS. TAMANA MAWARI
Credential	:	IBCLC
Telephone Number	:	313-428-2706

Provider Enumeration Date	:	01/23/2026
Last Update Date	:	01/23/2026

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