Provider Demographics
NPI:1760964878
Name:DALTON, DIETRA RACHEL (RN, BSN, IBCLC, CIMI)
Entity Type:Individual
Prefix:MRS
First Name:DIETRA
Middle Name:RACHEL
Last Name:DALTON
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC, CIMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 CRAGBURN PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-6404
Mailing Address - Country:US
Mailing Address - Phone:336-392-5384
Mailing Address - Fax:
Practice Address - Street 1:3237 CRAGBURN PL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-6404
Practice Address - Country:US
Practice Address - Phone:336-392-5384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC195908163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty