Provider Demographics
NPI:1285264416
Name:GAUDETTE, MICHELE (RN,IBCLC)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:GAUDETTE
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 1:4024 PENNY ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6636
Mailing Address - Country:US
Mailing Address - Phone:817-217-5027
Mailing Address - Fax:
Practice Address - Street 1:4024 PENNY ROYAL DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6636
Practice Address - Country:US
Practice Address - Phone:817-217-5027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX710796163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant