Provider Demographics
NPI:1356976906
Name:GRAVENOR, REBECCA (IBCLC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GRAVENOR
Suffix:
Gender:F
Credentials: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 316
Mailing Address - Street 2:
Mailing Address - City:MARDELA SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:21837-0316
Mailing Address - Country:US
Mailing Address - Phone:443-523-6373
Mailing Address - Fax:443-354-1853
Practice Address - Street 1:8077 BAPTIST CHURCH RD
Practice Address - Street 2:
Practice Address - City:MARDELA SPRINGS
Practice Address - State:MD
Practice Address - Zip Code:21837-2421
Practice Address - Country:US
Practice Address - Phone:443-523-6373
Practice Address - Fax:443-354-1853
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDL-134914174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN