Provider Demographics
NPI:1417793746
Name:WILDFLOWER LACTATION
Entity type:Organization
Organization Name:WILDFLOWER LACTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:IBCLC
Authorized Official - Phone:541-645-3018
Mailing Address - Street 1:462 SW VALERIA VIEW DR APT 303
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-7085
Mailing Address - Country:US
Mailing Address - Phone:503-755-8328
Mailing Address - Fax:
Practice Address - Street 1:3323 SW NAITO PKWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4672
Practice Address - Country:US
Practice Address - Phone:503-755-8328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500820297Medicaid