Provider Demographics
NPI:1124491766
Name:DISTEFANO, CARRIE (IBCLC)
Entity type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:
Last Name:DISTEFANO
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 1:5125 DEMARIE CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-5079
Mailing Address - Country:US
Mailing Address - Phone:360-918-2392
Mailing Address - Fax:
Practice Address - Street 1:5125 DEMARIE CT SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-5079
Practice Address - Country:US
Practice Address - Phone:360-918-2392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN