=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871339796
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANISHA MACKLIN LEATHERS RN, IBCLC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2024
-----------------------------------------------------
Last Update Date | 07/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4859 W SLAUSON AVE # 210
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90056-1290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-920-4196
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4859 W SLAUSON AVE # 210
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90056-1290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-920-4196
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number | 95201663
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number | L-315467
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------