Provider Demographics
NPI:1679103758
Name:GRESHAM, GAIL (IBCLC)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 CHERICO ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4002
Mailing Address - Country:US
Mailing Address - Phone:512-799-6155
Mailing Address - Fax:
Practice Address - Street 1:111 RAMBLE LN STE 115
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-2281
Practice Address - Country:US
Practice Address - Phone:512-808-0237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-15654174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN