Provider Demographics
NPI:1427746312
Name:WOMACK, BETHANY (IBCLC)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:WOMACK
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 1:418 E WILBUR RD APT 207
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-5476
Mailing Address - Country:US
Mailing Address - Phone:925-231-5143
Mailing Address - Fax:
Practice Address - Street 1:418 E WILBUR RD APT 207
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5476
Practice Address - Country:US
Practice Address - Phone:925-231-5143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
L-309538174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty