Provider Demographics
NPI:1942931779
Name:KIM, HEIDI CHRISTINA (IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:CHRISTINA
Last Name:KIM
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 1:30113 N SUNRAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-7524
Mailing Address - Country:US
Mailing Address - Phone:602-295-0796
Mailing Address - Fax:
Practice Address - Street 1:875 N GREENFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5044
Practice Address - Country:US
Practice Address - Phone:602-295-0796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-307740174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN