Provider Demographics
NPI:1902266919
Name:PROFESSIONAL BREASTFEEDING SUPPORT LLC
Entity Type:Organization
Organization Name:PROFESSIONAL BREASTFEEDING SUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/IBCLC
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANZICEK
Authorized Official - Suffix:
Authorized Official - Credentials:RN IBCLC
Authorized Official - Phone:248-795-1984
Mailing Address - Street 1:4630 W WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4630 W WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3535
Practice Address - Country:US
Practice Address - Phone:248-795-1984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty