Provider Demographics
NPI:1376202408
Name:SEPERACK, MEGHAN (IBCLC)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:SEPERACK
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 1:7707 CAMINITO LEON UNIT 202
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-8677
Mailing Address - Country:US
Mailing Address - Phone:916-844-5838
Mailing Address - Fax:
Practice Address - Street 1:8325 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-9322
Practice Address - Country:US
Practice Address - Phone:619-724-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-305245174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAL-305245OtherIBCLC