Provider Demographics
NPI:1194499467
Name:DAVIS, RANDI VERONICA (IBCLC)
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:VERONICA
Last Name:DAVIS
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 1:10275 PEOTONE DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-7744
Mailing Address - Country:US
Mailing Address - Phone:574-386-6394
Mailing Address - Fax:
Practice Address - Street 1:1001 COLORADO ST
Practice Address - Street 2:
Practice Address - City:WALKERTON
Practice Address - State:IN
Practice Address - Zip Code:46574-1086
Practice Address - Country:US
Practice Address - Phone:574-386-6394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INL-302748174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN