Provider Demographics
NPI:1144514407
Name:MERRILL, PHYLLIS GOODWIN (IBCLC)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:GOODWIN
Last Name:MERRILL
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:PEG
Other - Middle Name:
Other - Last Name:MERRILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:21522 W LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:PARKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21120-9110
Mailing Address - Country:US
Mailing Address - Phone:410-343-0023
Mailing Address - Fax:
Practice Address - Street 1:21522 W LIBERTY RD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:MD
Practice Address - Zip Code:21120-9110
Practice Address - Country:US
Practice Address - Phone:410-343-0023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-04
Last Update Date:2011-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
190-10574OtherINTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS (IBLCE)