Provider Demographics
NPI:1710558382
Name:SANTANA, NICOLE (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SANTANA
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5426 MIDVALE DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2326
Mailing Address - Country:US
Mailing Address - Phone:815-540-3613
Mailing Address - Fax:
Practice Address - Street 1:5426 MIDVALE DR UNIT A
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2326
Practice Address - Country:US
Practice Address - Phone:815-540-3613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL-307648163WL0100X
IL1809427174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No174N00000XOther Service ProvidersLactation Consultant, Non-RN