Provider Demographics
NPI:1730416793
Name:BEAULIEU, KIMBERLY G (IBCLC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:G
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MEDICAL CENTER DR
Mailing Address - Street 2:LACTATION SERVICES
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2652
Mailing Address - Country:US
Mailing Address - Phone:207-373-6530
Mailing Address - Fax:207-373-6526
Practice Address - Street 1:123 MEDICAL CENTER DR
Practice Address - Street 2:LACTATION SERVICES
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2652
Practice Address - Country:US
Practice Address - Phone:207-373-6530
Practice Address - Fax:207-373-6526
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERO27610163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant