MEDICARE: CAROLYNN WIMMER RN, IBCLC

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	163WM0102X	Maternal Newborn Registered Nurse	RN95225011	CA
2	163WL0100X	Lactation Consultant (Registered Nurse)	L-317218	CA

General Provider Information

NPI Number	:	1417757535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYNN WIMMER RN, IBCLC

Provider Business Mailing Address
First Line	:	4225 AVATI DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-4408
Country	:	US
Telephone Number	:	650-690-5094
Fax Number	:

Provider Business Practice Location Address
First Line	:	4225 AVATI DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-4408
Country	:	US
Telephone Number	:	650-690-5094
Fax Number	:

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

Provider Enumeration Date	:	03/17/2025
Last Update Date	:	06/30/2026

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