Provider Demographics
NPI:1255805875
Name:ANTHONIO, MICHELLE RUBY (IBCLC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RUBY
Last Name:ANTHONIO
Suffix:
Gender:
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 14TH ST APT 416
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-5380
Mailing Address - Country:US
Mailing Address - Phone:469-740-4448
Mailing Address - Fax:
Practice Address - Street 1:7447 WALLING LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-7337
Practice Address - Country:US
Practice Address - Phone:469-740-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
L-150024174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula