Provider Demographics
NPI:1902218290
Name:JOHNSON, SUSAN (IBCLC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
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:PO BOX 522425
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84152-2425
Mailing Address - Country:US
Mailing Address - Phone:801-580-4419
Mailing Address - Fax:
Practice Address - Street 1:2180 S 1300 E STE 600
Practice Address - Street 2:PARKVIEW PLAZA ONE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-4462
Practice Address - Country:US
Practice Address - Phone:801-580-4419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTL-17518174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN