Provider Demographics
NPI:1205421807
Name:BAZEMORE, HEATHER (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BAZEMORE
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 1:106 SOUTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-9266
Mailing Address - Country:US
Mailing Address - Phone:910-840-1135
Mailing Address - Fax:
Practice Address - Street 1:106 SOUTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-9266
Practice Address - Country:US
Practice Address - Phone:910-840-1135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC277755163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant