Provider Demographics
NPI:1952672974
Name:WELLES, ELISABETH C (IBCLC)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:C
Last Name:WELLES
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:LISSA
Other - Middle Name:ELISABETH
Other - Last Name:WELLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IBCLC
Mailing Address - Street 1:21 EMORY ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-2566
Mailing Address - Country:US
Mailing Address - Phone:551-655-5860
Mailing Address - Fax:
Practice Address - Street 1:21 EMORY ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-2566
Practice Address - Country:US
Practice Address - Phone:551-655-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11166120174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN