Individual
MARY WAGNER-DAVIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
IBCLC
Contact information
Practice address
604 FIFTEEN MILE DR, ROSEVILLE, CA 95678-5921
(916) 276-8016
Mailing address
PO BOX 176, ROSEVILLE, CA 95661-0176
(916) 276-8016
Taxonomy
Speciality
Code
Description
License number
State
106H00000X
Marriage & Family Therapist
MFC23253
CA
174N00000X
Lactation Consultant (Non-RN)
Primary
10218838
CA
Other
Enumeration date
03/18/2014
Last updated
03/18/2014
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