Provider Demographics
NPI:1063711422
Name:MAC, KATHERINE ROSE (IBCLC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROSE
Last Name:MAC
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ROSE
Other - Last Name:GIETZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:108 SUMMIT LOOP
Mailing Address - Street 2:C3
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-8792
Mailing Address - Country:US
Mailing Address - Phone:734-391-5547
Mailing Address - Fax:
Practice Address - Street 1:108 SUMMIT LOOP
Practice Address - Street 2:C3
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-8792
Practice Address - Country:US
Practice Address - Phone:734-391-5547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
11295806174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula