Provider Demographics
NPI:1265736995
Name:MATTSON, JULIE A (IBCLC, RN)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:A
Last Name:MATTSON
Suffix:
Gender:F
Credentials:IBCLC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 HIGHBUSH CT
Mailing Address - Street 2:
Mailing Address - City:DARDENNE PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63368-9765
Mailing Address - Country:US
Mailing Address - Phone:314-420-6331
Mailing Address - Fax:
Practice Address - Street 1:53 HIGHBUSH CT
Practice Address - Street 2:
Practice Address - City:DARDENNE PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63368-9765
Practice Address - Country:US
Practice Address - Phone:314-420-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003006871163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant