Healthcare Provider Details

I. General information

NPI: 1407086572
Provider Name (Legal Business Name): THERESA J JOHNSON RN, IBCLC, RLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9918 N JOHN ALBERT AVE
FRESNO CA
93720-4090
US

IV. Provider business mailing address

9918 N JOHN ALBERT AVE
FRESNO CA
93720-4090
US

V. Phone/Fax

Practice location:
  • Phone: 559-434-6937
  • Fax:
Mailing address:
  • Phone: 559-434-6937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN428962
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: