Provider Demographics
NPI:1558826289
Name:FUNK, ANGELA (IBCLC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FUNK
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 1:615 FREDRICKS AVE UNIT 122
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-1689
Mailing Address - Country:US
Mailing Address - Phone:760-580-8841
Mailing Address - Fax:
Practice Address - Street 1:615 FREDRICKS AVE UNIT 122
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1689
Practice Address - Country:US
Practice Address - Phone:760-580-8841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-136300174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE