Provider Demographics
NPI:1962235804
Name:CUSTIS, DECOLA (BSN, IBCLC)
Entity type:Individual
Prefix:
First Name:DECOLA
Middle Name:
Last Name:CUSTIS
Suffix:
Gender:F
Credentials:BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27457 BEACON RD
Mailing Address - Street 2:
Mailing Address - City:MELFA
Mailing Address - State:VA
Mailing Address - Zip Code:23410-3367
Mailing Address - Country:US
Mailing Address - Phone:757-709-4444
Mailing Address - Fax:
Practice Address - Street 1:27457 BEACON RD
Practice Address - Street 2:
Practice Address - City:MELFA
Practice Address - State:VA
Practice Address - Zip Code:23410-3367
Practice Address - Country:US
Practice Address - Phone:757-709-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001309544163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant