Healthcare Provider Details

I. General information

NPI: 1750837845
Provider Name (Legal Business Name): JULIE LYNN MALLOCH RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 TURF LN
EAST LANSING MI
48823-6392
US

IV. Provider business mailing address

1560 TURF LN
EAST LANSING MI
48823-6392
US

V. Phone/Fax

Practice location:
  • Phone: 517-484-3000
  • Fax: 517-484-6358
Mailing address:
  • Phone: 517-484-3000
  • Fax: 517-484-6358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number4704285480
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704285480
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: