Provider Demographics
NPI:1891463311
Name:UTRATA, LYNN R (RN IBCLC)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:R
Last Name:UTRATA
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 1:10850 PROVIDENCE ROAD
Mailing Address - Street 2:1109
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2684
Mailing Address - Country:US
Mailing Address - Phone:704-626-9123
Mailing Address - Fax:
Practice Address - Street 1:6135 PARK SOUTH DR SUITE 510
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210
Practice Address - Country:US
Practice Address - Phone:704-626-9123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL-34706163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant