Provider Demographics
NPI:1972046928
Name:FISH, BERNADETTE (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:FISH
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-0254
Mailing Address - Country:US
Mailing Address - Phone:801-830-0109
Mailing Address - Fax:
Practice Address - Street 1:331 N 400 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1913
Practice Address - Country:US
Practice Address - Phone:801-830-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3241653102163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant