Provider Demographics
NPI:1104424365
Name:PROLACTIN LIFE, LLC
Entity type:Organization
Organization Name:PROLACTIN LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WYSONG
Authorized Official - Suffix:
Authorized Official - Credentials:RN, IBCLC
Authorized Official - Phone:240-360-1205
Mailing Address - Street 1:15012 NOTLEY RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-7437
Mailing Address - Country:US
Mailing Address - Phone:240-360-1205
Mailing Address - Fax:
Practice Address - Street 1:15012 NOTLEY RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20905-7437
Practice Address - Country:US
Practice Address - Phone:240-360-1205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty