Provider Demographics
NPI:1932509106
Name:FAWKES, KRISTIE (IBCLC)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:FAWKES
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 1:601 PITNEY DR APT 4
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07762-2262
Mailing Address - Country:US
Mailing Address - Phone:617-640-3148
Mailing Address - Fax:
Practice Address - Street 1:601 PITNEY DR APT 4
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07762-2262
Practice Address - Country:US
Practice Address - Phone:617-640-3148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11134129174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN