Provider Demographics
NPI:1255733432
Name:WENTZEL, MEREDITH (IBCLC, LMBT)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:WENTZEL
Suffix:
Gender:F
Credentials:IBCLC, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MEADOW BLOSSOM WAY
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6588
Mailing Address - Country:US
Mailing Address - Phone:864-497-6555
Mailing Address - Fax:
Practice Address - Street 1:319 GARLINGTON RD STE D9
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4610
Practice Address - Country:US
Practice Address - Phone:864-757-4951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4807174400000X
SC79127174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1255733432Medicaid