MEDICARE: MRS. STEPHANIE ILENE MINNICH CBC

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	:	1326514225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE ILENE MINNICH CBC

Provider Business Mailing Address
First Line	:	3016 AVENUE I
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3033
Country	:	US
Telephone Number	:	301-440-5663
Fax Number	:

Provider Business Practice Location Address
First Line	:	3016 AVENUE I
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11210-3033
Country	:	US
Telephone Number	:	301-440-5663
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2018
Last Update Date	:	10/17/2018

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