Provider Demographics
NPI:1598311730
Name:LARSON, AMY (IBCLC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:SHIREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:468 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19547-9256
Mailing Address - Country:US
Mailing Address - Phone:610-655-5178
Mailing Address - Fax:
Practice Address - Street 1:468 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEY
Practice Address - State:PA
Practice Address - Zip Code:19547-9256
Practice Address - Country:US
Practice Address - Phone:610-655-5178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-157668174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN