MEDICARE: MELISSA FAITH ANDERSON CLACKUM IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)	L-303290	GA

General Provider Information

NPI Number	:	1043942956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA FAITH ANDERSON CLACKUM IBCLC

Provider Business Mailing Address
First Line	:	2141 KINGSTON CT SE STE 103
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-8928
Country	:	US
Telephone Number	:	770-644-0555
Fax Number	:	770-644-0514

Provider Business Practice Location Address
First Line	:	2141 KINGSTON CT SE STE 103
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-8928
Country	:	US
Telephone Number	:	770-644-0555
Fax Number	:	770-644-0514

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2022
Last Update Date	:	06/29/2022

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