Provider Demographics
NPI:1114462520
Name:NEVAREZ, EDEN (IBCLC)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:NEVAREZ
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 1:3620 SE 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-1390
Mailing Address - Country:US
Mailing Address - Phone:305-915-9389
Mailing Address - Fax:
Practice Address - Street 1:3620 SE 54TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34480-1390
Practice Address - Country:US
Practice Address - Phone:305-915-9389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL-82864174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
81-4756277OtherEIN