Provider Demographics
NPI:1629576046
Name:MANCE, MEREDITH BROOKE (CPM, LDM, IBCLC)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:BROOKE
Last Name:MANCE
Suffix:
Gender:F
Credentials:CPM, LDM, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 SE FORD ST APT 22
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6352
Mailing Address - Country:US
Mailing Address - Phone:213-448-2355
Mailing Address - Fax:
Practice Address - Street 1:855 SE FORD ST APT 22
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6352
Practice Address - Country:US
Practice Address - Phone:213-448-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99320176B00000X
L-149934174N00000X
ORDEM-LD-10195740176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No174N00000XOther Service ProvidersLactation Consultant, Non-RN