Provider Demographics
NPI:1386988863
Name:WISNER, WENDY MICHELLE (IBCLC)
Entity type:Individual
Prefix:MS
First Name:WENDY
Middle Name:MICHELLE
Last Name:WISNER
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 1:4714 217TH ST
Mailing Address - Street 2:2A
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3501
Mailing Address - Country:US
Mailing Address - Phone:718-224-1433
Mailing Address - Fax:
Practice Address - Street 1:4714 217TH ST
Practice Address - Street 2:2A
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3501
Practice Address - Country:US
Practice Address - Phone:718-224-1433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11295549174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN