Provider Demographics
NPI:1063705085
Name:OWEN, MARY ELIZABETH (RN,IBCLC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:OWEN
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 1:1725 PINE ST
Mailing Address - Street 2:JACKSON HOSPITAL (4 WEST-LACTATION OFFICE)
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1109
Mailing Address - Country:US
Mailing Address - Phone:334-293-8000
Mailing Address - Fax:
Practice Address - Street 1:1725 PINE ST
Practice Address - Street 2:JACKSON HOSPITAL (4 WEST-LACTATION OFFICE)
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1109
Practice Address - Country:US
Practice Address - Phone:334-293-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALIBCLC #108-12747163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-028903OtherBOARD OF NURSING-RN LICENSE