Healthcare Provider Details

I. General information

NPI: 1306963905
Provider Name (Legal Business Name): MICAELA DAWN ANDERSON RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 E 3RD ST
CHATTANOOGA TN
37403-2102
US

IV. Provider business mailing address

5115 HUNTER VILLAGE DR
OOLTEWAH TN
37363-9046
US

V. Phone/Fax

Practice location:
  • Phone: 423-209-8321
  • Fax:
Mailing address:
  • Phone: 423-238-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN0000136821
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: