Healthcare Provider Details

I. General information

NPI: 1053659581
Provider Name (Legal Business Name): MELISSA ARLANE LANDRETH RNC, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SAINT FRANCIS DR
CAPE GIRARDEAU MO
63703-5049
US

IV. Provider business mailing address

4916 PINEDALE
JACKSON MO
63755-2521
US

V. Phone/Fax

Practice location:
  • Phone: 573-331-5565
  • Fax:
Mailing address:
  • Phone: 573-339-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number116460
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: