Provider Demographics
NPI:1154050417
Name:GRANTO PENQUE, GINA (IBCLC, RLC)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:GRANTO PENQUE
Suffix:
Gender:F
Credentials:IBCLC, RLC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:PENQUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:618 1/2 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14305-1802
Mailing Address - Country:US
Mailing Address - Phone:716-285-1279
Mailing Address - Fax:
Practice Address - Street 1:618 1/2 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14305-1802
Practice Address - Country:US
Practice Address - Phone:716-998-3472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN