Healthcare Provider Details

I. General information

NPI: 1629666151
Provider Name (Legal Business Name): MIKAELA JOHNSON JOHNSON VAAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2021
Last Update Date: 01/10/2021
Certification Date: 01/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5585 COCHRAN ST APT 188
SIMI VALLEY CA
93063-6561
US

IV. Provider business mailing address

5585 COCHRAN ST APT 188
SIMI VALLEY CA
93063-6561
US

V. Phone/Fax

Practice location:
  • Phone: 719-650-8158
  • Fax:
Mailing address:
  • Phone: 719-650-8158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number77019
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number026333
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: