Provider Demographics
NPI:1659854032
Name:DAVIS, DOREEN SULLIVAN (IBCLC)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:SULLIVAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:MS
Other - First Name:DOREEN
Other - Middle Name:ANN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 SPRUCE LN
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1668
Mailing Address - Country:US
Mailing Address - Phone:860-798-4239
Mailing Address - Fax:
Practice Address - Street 1:20 SPRUCE LN
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1668
Practice Address - Country:US
Practice Address - Phone:860-798-4239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-141813174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN