Provider Demographics
NPI:1821595893
Name:MATHE, MARILYN MARIE (IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:MARIE
Last Name:MATHE
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:PO BOX 576
Mailing Address - Street 2:
Mailing Address - City:CORNVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86325-0576
Mailing Address - Country:US
Mailing Address - Phone:928-634-5844
Mailing Address - Fax:
Practice Address - Street 1:269 S CANDY LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4170
Practice Address - Country:US
Practice Address - Phone:928-639-6520
Practice Address - Fax:928-639-6647
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN087022163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty