Provider Demographics
NPI:1730591629
Name:WAGNILD, AMANDA MARY-BETH (IBCLC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARY-BETH
Last Name:WAGNILD
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 1:105 TERRACE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6256
Mailing Address - Country:US
Mailing Address - Phone:607-220-6656
Mailing Address - Fax:
Practice Address - Street 1:105 TERRACE VIEW DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-6256
Practice Address - Country:US
Practice Address - Phone:607-220-6656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
L-308554174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula