Provider Demographics
NPI:1629656962
Name:GAGNE, CLARE (CLC)
Entity Type:Individual
Prefix:
First Name:CLARE
Middle Name:
Last Name:GAGNE
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 WOODWARD AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1357
Mailing Address - Country:US
Mailing Address - Phone:414-943-3488
Mailing Address - Fax:
Practice Address - Street 1:376 WOODWARD AVE APT 2R
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1357
Practice Address - Country:US
Practice Address - Phone:414-943-3488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAALLP-310860174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN