Provider Demographics
NPI:1780238386
Name:GREGORY, COURTNEY MARIE (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 RAEGAN WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4526
Mailing Address - Country:US
Mailing Address - Phone:415-640-8512
Mailing Address - Fax:
Practice Address - Street 1:1501 RAEGAN WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4526
Practice Address - Country:US
Practice Address - Phone:415-640-8512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA653350163W00000X
CAL87781163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse