Provider Demographics
NPI:1073222196
Name:HEDWALL, TRACIE (BSN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:
Last Name:HEDWALL
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 1:2801 THURLOE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-3149
Mailing Address - Country:US
Mailing Address - Phone:804-241-7599
Mailing Address - Fax:
Practice Address - Street 1:2801 THURLOE DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-3149
Practice Address - Country:US
Practice Address - Phone:804-241-7599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001174953163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty