Provider Demographics
NPI:1922398056
Name:MESIBOV, LENORA S (IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:LENORA
Middle Name:S
Last Name:MESIBOV
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 1:168 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-2510
Mailing Address - Country:US
Mailing Address - Phone:845-365-3917
Mailing Address - Fax:
Practice Address - Street 1:168 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:TAPPAN
Practice Address - State:NY
Practice Address - Zip Code:10983
Practice Address - Country:US
Practice Address - Phone:845-365-3917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA10991724174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10991724OtherLACTATION CONSULTANT, NON-RN CLASSIFICATION,