Provider Demographics
NPI:1144090630
Name:SOUTHARD, ANITA MIEKO
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:MIEKO
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 VERNON ST APT 312
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-2367
Mailing Address - Country:US
Mailing Address - Phone:916-500-9691
Mailing Address - Fax:
Practice Address - Street 1:623 VERNON ST APT 312
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2367
Practice Address - Country:US
Practice Address - Phone:916-500-9691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174H00000XOther Service ProvidersHealth Educator
No174N00000XOther Service ProvidersLactation Consultant, Non-RN