MEDICARE: MARLENE LOUISE WARK 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)	537115	TX

General Provider Information

NPI Number	:	1508113150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLENE LOUISE WARK RN, IBCLC, RLC

Provider Business Mailing Address
First Line	:	2636 SOUTH LOOP WEST
Second Line	:	SUITE 135
City	:	HOUSTON
State	:	TX
Zip	:	77054
Country	:	US
Telephone Number	:	713-839-0527
Fax Number	:	713-839-0683

Provider Business Practice Location Address
First Line	:	2636 SOUTH LOOP WEST
Second Line	:	SUITE 135
City	:	HOUSTON
State	:	TX
Zip	:	77054
Country	:	US
Telephone Number	:	713-839-0527
Fax Number	:	713-839-0683

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

Provider Enumeration Date	:	08/13/2012
Last Update Date	:	08/13/2012

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