Provider Demographics
NPI:1598461717
Name:RICHARDSON, MARY LAURA (MS, BA, RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LAURA
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MS, BA, RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 VISTA DEL SOL PT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-8007
Mailing Address - Country:US
Mailing Address - Phone:717-377-2568
Mailing Address - Fax:
Practice Address - Street 1:5025 VISTA DEL SOL PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-8007
Practice Address - Country:US
Practice Address - Phone:717-377-2568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1653683163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty