Healthcare Provider Details

I. General information

NPI: 1255805875
Provider Name (Legal Business Name): MICHELLE RUBY ANTHONIO IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 WALLING LN
DALLAS TX
75231-7337
US

IV. Provider business mailing address

1834 14TH ST APT 416
SANTA MONICA CA
90404-5380
US

V. Phone/Fax

Practice location:
  • Phone: 469-740-4448
  • Fax:
Mailing address:
  • Phone: 469-740-4448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-150024
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: