Provider Demographics
NPI:1821500877
Name:WHITACRE, MISHELL GREENVILLE (LM, IBCLC)
Entity Type:Individual
Prefix:
First Name:MISHELL
Middle Name:GREENVILLE
Last Name:WHITACRE
Suffix:
Gender:F
Credentials:LM, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4665 PORTOLA WAY
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-2300
Mailing Address - Country:US
Mailing Address - Phone:805-400-8231
Mailing Address - Fax:
Practice Address - Street 1:4665 PORTOLA WAY
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-2300
Practice Address - Country:US
Practice Address - Phone:805-400-8231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM502176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALM502OtherMIDWIFE LICENSE
CAL-62666OtherBOARD CERTIFIED LACTATION CONSULTANT