Provider Demographics
NPI:1821412685
Name:MACNICHOL, TERRI (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:MACNICHOL
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 1:820 N WALLACE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3024
Mailing Address - Country:US
Mailing Address - Phone:253-278-5740
Mailing Address - Fax:
Practice Address - Street 1:820 N WALLACE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3024
Practice Address - Country:US
Practice Address - Phone:253-278-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN46899163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant