Provider Demographics
NPI:1932681624
Name:PRINCE, NICHOLANNA (IBCLC)
Entity Type:Individual
Prefix:
First Name:NICHOLANNA
Middle Name:
Last Name:PRINCE
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 1:505 MOUNT PARNASSUS RD
Mailing Address - Street 2:
Mailing Address - City:EAST HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06423-1532
Mailing Address - Country:US
Mailing Address - Phone:860-729-2970
Mailing Address - Fax:
Practice Address - Street 1:505 MOUNT PARNASSUS RD
Practice Address - Street 2:
Practice Address - City:EAST HADDAM
Practice Address - State:CT
Practice Address - Zip Code:06423-1532
Practice Address - Country:US
Practice Address - Phone:860-729-2970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2022-02-02
Deactivation Date:2021-02-12
Deactivation Code:
Reactivation Date:2022-02-02
Provider Licenses
StateLicense IDTaxonomies
CT129988174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN