Provider Demographics
NPI:1447760475
Name:NICKLAS, SUZANNE MICHELE (IBCLC)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:MICHELE
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 AMARYLLIS AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-5598
Mailing Address - Country:US
Mailing Address - Phone:518-788-4988
Mailing Address - Fax:
Practice Address - Street 1:101 AMARYLLIS AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-5598
Practice Address - Country:US
Practice Address - Phone:518-788-4988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCL-87707163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant