Provider Demographics
NPI:1275280588
Name:BLUMER-BUELL, KOALI ANYA (IBCLC)
Entity Type:Individual
Prefix:
First Name:KOALI
Middle Name:ANYA
Last Name:BLUMER-BUELL
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 N HAIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2121
Mailing Address - Country:US
Mailing Address - Phone:503-888-7346
Mailing Address - Fax:
Practice Address - Street 1:6355 N HAIGHT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2121
Practice Address - Country:US
Practice Address - Phone:503-888-7346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLC-LC-10220125174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORLC-LC-10220125OtherOREGON HEALTH LICENSING