Provider Demographics
NPI:1780412593
Name:CHARBONEAU, ALYSSA (RN, IBCLC, CLC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:CHARBONEAU
Suffix:
Gender:F
Credentials:RN, IBCLC, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 MODOC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4124
Mailing Address - Country:US
Mailing Address - Phone:541-206-7970
Mailing Address - Fax:
Practice Address - Street 1:1361 MODOC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4124
Practice Address - Country:US
Practice Address - Phone:541-206-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201800176RN163WL0100X
ORL-315382163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant