Provider Demographics
NPI:1346925476
Name:LEWELLEN, LAURA MARIE (IBCLC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:LEWELLEN
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 1:913 WHITE HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48356-1665
Mailing Address - Country:US
Mailing Address - Phone:248-431-2588
Mailing Address - Fax:
Practice Address - Street 1:3362 PARKLAND DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-1828
Practice Address - Country:US
Practice Address - Phone:248-425-0702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704115816174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty