Provider Demographics
NPI:1871268045
Name:BEUTEL, MICHELLE MARIE (IBCLC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:BEUTEL
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 1:1230 N SAN JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1426
Mailing Address - Country:US
Mailing Address - Phone:209-756-4058
Mailing Address - Fax:
Practice Address - Street 1:1230 N SAN JOAQUIN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1426
Practice Address - Country:US
Practice Address - Phone:209-756-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-12018174400000X, 174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No174400000XOther Service ProvidersSpecialist