Provider Demographics
NPI:1649518648
Name:FORTIN, YOLANDA BLACK (PHD, IBCLC)
Entity type:Individual
Prefix:
First Name:YOLANDA
Middle Name:BLACK
Last Name:FORTIN
Suffix:
Gender:F
Credentials:PHD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MAYER CT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92617-4113
Mailing Address - Country:US
Mailing Address - Phone:617-970-3046
Mailing Address - Fax:949-854-7154
Practice Address - Street 1:22 MAYER CT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92617-4113
Practice Address - Country:US
Practice Address - Phone:617-970-3046
Practice Address - Fax:949-854-7154
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN