Provider Demographics
NPI:1750130456
Name:NOURISHED ROOTS LACTATION LLC
Entity type:Organization
Organization Name:NOURISHED ROOTS LACTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GINN
Authorized Official - Suffix:
Authorized Official - Credentials:IBCLC
Authorized Official - Phone:336-287-2042
Mailing Address - Street 1:1702 LONE HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-6242
Mailing Address - Country:US
Mailing Address - Phone:336-287-2042
Mailing Address - Fax:
Practice Address - Street 1:211 W WACKER DR STE 120
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-1377
Practice Address - Country:US
Practice Address - Phone:336-287-2042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-15
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty