Healthcare Provider Details

I. General information

NPI: 1962164467
Provider Name (Legal Business Name): JUANITA NICOLE ALLEN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 06/30/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 CAPLIN ST
HOUSTON TX
77026-1104
US

IV. Provider business mailing address

2602 CAPLIN ST
HOUSTON TX
77026-1104
US

V. Phone/Fax

Practice location:
  • Phone: 979-703-9123
  • Fax:
Mailing address:
  • Phone: 979-703-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-308020
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: