Provider Demographics
NPI:1205658945
Name:WILD MILK PLLC
Entity type:Organization
Organization Name:WILD MILK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGASPI
Authorized Official - Suffix:
Authorized Official - Credentials:RN, IBCLC
Authorized Official - Phone:310-989-4820
Mailing Address - Street 1:10960 W THREADGRASS ST
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-6334
Mailing Address - Country:US
Mailing Address - Phone:310-989-4820
Mailing Address - Fax:
Practice Address - Street 1:4946 E SAWMILL WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-6700
Practice Address - Country:US
Practice Address - Phone:209-765-2399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty