MEDICARE: AMANDA MARY-BETH WAGNILD 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	374J00000X	Doula
2	174N00000X	Lactation Consultant (Non-RN)	L-308554

General Provider Information

NPI Number	:	1730591629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MARY-BETH WAGNILD IBCLC

Provider Business Mailing Address
First Line	:	105 TERRACE VIEW DR
Second Line	:
City	:	ITHACA
State	:	NY
Zip	:	14850-6256
Country	:	US
Telephone Number	:	607-220-6656
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 TERRACE VIEW DR
Second Line	:
City	:	ITHACA
State	:	NY
Zip	:	14850-6256
Country	:	US
Telephone Number	:	607-220-6656
Fax Number	:

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

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	09/15/2025

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