Provider Demographics
NPI:1710798285
Name:WALLACE, COURTNEY MARIE (RN, PHN, IBCLC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN, PHN, IBCLC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:MARIE
Other - Last Name:HULTGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:363 BARRY DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-1495
Mailing Address - Country:US
Mailing Address - Phone:805-798-1596
Mailing Address - Fax:
Practice Address - Street 1:363 BARRY DR
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-1495
Practice Address - Country:US
Practice Address - Phone:805-798-1596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA821163163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty