MEDICARE: KACEY LAINE HECKATHORN RN, BSN, 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-309407	MD
2	163WL0100X	Lactation Consultant (Registered Nurse)	R232561	MD

General Provider Information

NPI Number	:	1871371336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KACEY LAINE HECKATHORN RN, BSN, IBCLC

Provider Business Mailing Address
First Line	:	9925 MORGANTOWN RD
Second Line	:
City	:	NEWBURG
State	:	MD
Zip	:	20664-2318
Country	:	US
Telephone Number	:	240-320-4202
Fax Number	:

Provider Business Practice Location Address
First Line	:	9925 MORGANTOWN RD
Second Line	:
City	:	NEWBURG
State	:	MD
Zip	:	20664-2318
Country	:	US
Telephone Number	:	240-320-4202
Fax Number	:

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

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	09/18/2023

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