Provider Demographics
NPI:1114533387
Name:OWEN, GAYLE ANNE (RN IBCLC LC)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:ANNE
Last Name:OWEN
Suffix:
Gender:F
Credentials:RN IBCLC LC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 BANKSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKS
Mailing Address - State:GA
Mailing Address - Zip Code:30205-2219
Mailing Address - Country:US
Mailing Address - Phone:770-856-0890
Mailing Address - Fax:
Practice Address - Street 1:596 BANKSTOWN RD
Practice Address - Street 2:
Practice Address - City:BROOKS
Practice Address - State:GA
Practice Address - Zip Code:30205-2219
Practice Address - Country:US
Practice Address - Phone:770-856-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA077331163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA28744OtherLACTATION