Provider Demographics
NPI:1710441928
Name:SONNEVILLE-DOUGLASS, KIRSTEN A (IBCLC)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:A
Last Name:SONNEVILLE-DOUGLASS
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 1:1703 MADDY LN
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1156
Mailing Address - Country:US
Mailing Address - Phone:248-202-9771
Mailing Address - Fax:
Practice Address - Street 1:1703 MADDY LN
Practice Address - Street 2:
Practice Address - City:KEEGO HARBOR
Practice Address - State:MI
Practice Address - Zip Code:48320-1156
Practice Address - Country:US
Practice Address - Phone:248-202-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-133099174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN