Provider Demographics
NPI:1154856102
Name:ANDERSON, SUZANNE W (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:W
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MCLAUGHLIN LN
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-6802
Mailing Address - Country:US
Mailing Address - Phone:505-306-1091
Mailing Address - Fax:
Practice Address - Street 1:30 MCLAUGHLIN LN
Practice Address - Street 2:
Practice Address - City:SANDIA PARK
Practice Address - State:NM
Practice Address - Zip Code:87047-6802
Practice Address - Country:US
Practice Address - Phone:505-306-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML-10364174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN