Provider Demographics
NPI:1225601867
Name:JOHNSON, MELISSA ROSE (IBCLC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ROSE
Last Name:JOHNSON
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 1:12862 OLD FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-1213
Mailing Address - Country:US
Mailing Address - Phone:714-308-0855
Mailing Address - Fax:
Practice Address - Street 1:12862 OLD FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-1213
Practice Address - Country:US
Practice Address - Phone:714-308-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-17562174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN