Provider Demographics
NPI:1750084414
Name:SOUTHERLAND, DEVON (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4666 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9335
Mailing Address - Country:US
Mailing Address - Phone:616-648-7689
Mailing Address - Fax:
Practice Address - Street 1:233 FULTON ST E STE 114
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3261
Practice Address - Country:US
Practice Address - Phone:616-648-7689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704314609163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant