Healthcare Provider Details

I. General information

NPI: 1194175893
Provider Name (Legal Business Name): MELISSA CAMPBELL DONOVAN RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 LAKEWIND CT
ALPHARETTA GA
30005-4288
US

IV. Provider business mailing address

2710 LAKEWIND CT
ALPHARETTA GA
30005-4288
US

V. Phone/Fax

Practice location:
  • Phone: 404-556-3206
  • Fax:
Mailing address:
  • Phone: 404-556-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-87069
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: