Provider Demographics
NPI:1720701741
Name:BALLARD, SANDRA (IBCLC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BALLARD
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 1:2245 N 400 E STE 204
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1785
Mailing Address - Country:US
Mailing Address - Phone:435-554-1208
Mailing Address - Fax:
Practice Address - Street 1:2245 NORTH 400 EAST
Practice Address - Street 2:SUITE 202
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-554-1208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTL-17810174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN