MEDICARE: SUZANNE NUNNALLY BSN, RN, IBCLC, RLC

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	163WL0100X	Lactation Consultant (Registered Nurse)	L-33226	GA

General Provider Information

NPI Number	:	1336863232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE NUNNALLY BSN, RN, IBCLC, RLC

Provider Business Mailing Address
First Line	:	84 KINNEY CREEK LN
Second Line	:
City	:	PENDERGRASS
State	:	GA
Zip	:	30567-2281
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	84 KINNEY CREEK LN
Second Line	:
City	:	PENDERGRASS
State	:	GA
Zip	:	30567-2281
Country	:	US
Telephone Number	:	678-617-0640
Fax Number	:

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

Provider Enumeration Date	:	10/04/2022
Last Update Date	:	10/04/2022

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