Provider Demographics
NPI:1720807357
Name:WAGER, LATASHA MONIQUE (IBCLC)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:MONIQUE
Last Name:WAGER
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 1:22529 N CELTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-8899
Mailing Address - Country:US
Mailing Address - Phone:480-766-2908
Mailing Address - Fax:
Practice Address - Street 1:22529 N CELTIC AVE
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-8899
Practice Address - Country:US
Practice Address - Phone:480-766-2908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL-312763174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN