Provider Demographics
NPI:1497229710
Name:PETERSON, MOLLY G (BS, IBCLC, RLC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BS, IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6109 73RD ST APT 201
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3561
Mailing Address - Country:US
Mailing Address - Phone:815-761-6877
Mailing Address - Fax:
Practice Address - Street 1:530 N 108TH PL
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4253
Practice Address - Country:US
Practice Address - Phone:414-231-9640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN