Provider Demographics
NPI:1053797159
Name:RADOCCIA-KENNEN, MAYA (IBCLC)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:RADOCCIA-KENNEN
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:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:CLARKDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:86324-0225
Mailing Address - Country:US
Mailing Address - Phone:928-301-3274
Mailing Address - Fax:
Practice Address - Street 1:510 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKDALE
Practice Address - State:AZ
Practice Address - Zip Code:86324
Practice Address - Country:US
Practice Address - Phone:928-301-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN