Provider Demographics
NPI:1154066512
Name:PETERS, SYDNEY (IBCLC)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:SYDNEY
Other - Middle Name:
Other - Last Name:MCCOLLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1430 HAINES AVE STE 108 PMB 311
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 38TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3108
Practice Address - Country:US
Practice Address - Phone:605-416-1778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-30
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X, 374J00000X
L-310202174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No174H00000XOther Service ProvidersHealth Educator
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
L-310202OtherINTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS