Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 174N00000X | Lactation Consultant | L-126472 | ID |
NPI | 1205314606 |
---|---|
Provider Name | Melanie Henstrom |
First Address | Boise, ID 83716-5831 |
Second Address | Boise, ID 83716-5831 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2018 |
Last Update Date | 30/07/2018 |