Provider Demographics
NPI:1245747914
Name:MILKY MAMA
Entity Type:Organization
Organization Name:MILKY MAMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:N
Authorized Official - Last Name:DUHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, IBCLC
Authorized Official - Phone:951-347-8730
Mailing Address - Street 1:10722 ARROW RTE STE 104
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4809
Mailing Address - Country:US
Mailing Address - Phone:877-886-4559
Mailing Address - Fax:
Practice Address - Street 1:10722 ARROW RTE STE 104
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4809
Practice Address - Country:US
Practice Address - Phone:877-886-4559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA818893163WL0100X
174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty