Provider Demographics
NPI:1710228143
Name:REID, NICOLE (IBCLC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:REID
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 1:2740 INNISBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7872
Mailing Address - Country:US
Mailing Address - Phone:269-203-5484
Mailing Address - Fax:
Practice Address - Street 1:2740 INNISBROOK DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7872
Practice Address - Country:US
Practice Address - Phone:269-203-5484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN108-25456174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN