Provider Demographics
NPI:1902365869
Name:ADVANCED BREASTFEEDING SUPPORT OF LAS VEGAS
Entity Type:Organization
Organization Name:ADVANCED BREASTFEEDING SUPPORT OF LAS VEGAS
Other - Org Name:AUTUMN WAKE, RN, BSN, IBCLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, IBCLC
Authorized Official - Phone:702-764-9290
Mailing Address - Street 1:6970 S CIMARRON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2135
Mailing Address - Country:US
Mailing Address - Phone:702-764-9290
Mailing Address - Fax:702-473-5383
Practice Address - Street 1:6970 S CIMARRON RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2135
Practice Address - Country:US
Practice Address - Phone:702-764-9290
Practice Address - Fax:702-473-5383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-19
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty