Provider Demographics
NPI:1770977332
Name:JOHNSON-HADDAD, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:JOHNSON-HADDAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:JOHNSON-HADDAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IBCLC
Mailing Address - Street 1:763 S OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3722
Mailing Address - Country:US
Mailing Address - Phone:818-621-5477
Mailing Address - Fax:
Practice Address - Street 1:763 S OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-3722
Practice Address - Country:US
Practice Address - Phone:818-621-5477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-22
Last Update Date:2015-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-17582174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN