Provider Demographics
NPI:1417728684
Name:STALLWORTH, COURTNEY (BSN RN IBCLC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:BSN RN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S. PERRY STREET
Mailing Address - Street 2:SUITE 206 #9313
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:678-712-8583
Mailing Address - Fax:
Practice Address - Street 1:113 S. PERRY STREET
Practice Address - Street 2:SUITE 206 #9313
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:678-712-8583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN201879163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant