Healthcare Provider Details

I. General information

NPI: 1477079267
Provider Name (Legal Business Name): SHIRA JOHNSON IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4804 CASCADE RD SE
GRAND RAPIDS MI
49546-3721
US

IV. Provider business mailing address

2475 SINCLAIR AVE NE
GRAND RAPIDS MI
49505-3602
US

V. Phone/Fax

Practice location:
  • Phone: 517-281-5814
  • Fax:
Mailing address:
  • Phone: 517-281-5814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-108335
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: