Provider Demographics
NPI:1942789219
Name:GOURLEY, KRISTIN (IBCLC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:GOURLEY
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 1:12672 N ANGELS GATE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3849
Mailing Address - Country:US
Mailing Address - Phone:801-647-3669
Mailing Address - Fax:
Practice Address - Street 1:12672 N ANGELS GATE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-3849
Practice Address - Country:US
Practice Address - Phone:801-647-3669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty