MEDICARE: MRS. REBECCA LYNN BANDEEN 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	163WL0100X	Lactation Consultant (Registered Nurse)	RN144575	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659918357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA LYNN BANDEEN IBCLC

Provider Business Mailing Address
First Line	:	6610 W CORDIA LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85083-7404
Country	:	US
Telephone Number	:	623-824-3660
Fax Number	:	623-572-9405

Provider Business Practice Location Address
First Line	:	6610 W CORDIA LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85083-7404
Country	:	US
Telephone Number	:	623-824-3660
Fax Number	:	623-572-9405

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

Provider Enumeration Date	:	12/02/2019
Last Update Date	:	12/02/2019

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