MEDICARE: GAIL DITTES 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	163WL0100X	Lactation Consultant (Registered Nurse)	L-46563	PA

General Provider Information

NPI Number	:	1811326564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAIL DITTES RN IBCLC

Provider Business Mailing Address
First Line	:	17 SHELLFLOWER RD
Second Line	:
City	:	LEVITTOWN
State	:	PA
Zip	:	19056-1707
Country	:	US
Telephone Number	:	267-879-5000
Fax Number	:	267-393-4500

Provider Business Practice Location Address
First Line	:	17 SHELLFLOWER RD
Second Line	:
City	:	LEVITTOWN
State	:	PA
Zip	:	19056-1707
Country	:	US
Telephone Number	:	267-241-1432
Fax Number	:

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

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	10/02/2014

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