Provider Demographics
NPI:1831618370
Name:WISNER, MADELEINE JUSTINE (LM, IBCLC)
Entity type:Individual
Prefix:MISS
First Name:MADELEINE
Middle Name:JUSTINE
Last Name:WISNER
Suffix:
Gender:F
Credentials:LM, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5960 SOUTH LAND PARK DRIVE
Mailing Address - Street 2:PMB 302
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822
Mailing Address - Country:US
Mailing Address - Phone:916-668-9467
Mailing Address - Fax:209-336-6814
Practice Address - Street 1:2541 28TH ST #4 SACRAMENTO
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818
Practice Address - Country:US
Practice Address - Phone:916-668-9467
Practice Address - Fax:209-336-6814
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X, 374J00000X
CA510176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831618370Medicaid