Provider Demographics
NPI:1285511683
Name:MALLARD, IMANI SADE (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:SADE
Last Name:MALLARD
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 1:10945 PRICE MANOR WAY
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-6036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 19TH ST NW STE 150
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-6103
Practice Address - Country:US
Practice Address - Phone:202-293-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR254502163WN0002X
DCRN500016940163WN0003X
MDL-319151163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk