Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 174N00000X | Lactation Consultant | 11132727 | AZ |
NPI | 1295087203 |
---|---|
Provider Name | Eileen Kim Petrocelli |
First Address | Prescott, AZ 86305-3700 |
Second Address | Prescott Valley, AZ 86314-2255 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/10/2012 |
Last Update Date | 15/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
11132727 | IBCLC (01) | AZ |