Provider Demographics
NPI:1124696539
Name:HEATHER MARIE LACTATION, LLC
Entity type:Organization
Organization Name:HEATHER MARIE LACTATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:THEUT-JABLONOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-587-8634
Mailing Address - Street 1:1246 WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-2080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1246 WEST BLVD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-2080
Practice Address - Country:US
Practice Address - Phone:248-587-8634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty