Provider Demographics
NPI:1730779356
Name:JOHNSON, HOLLY (IBCLC)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7811 LIGHT FIGHTER DR APT C
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80902-4644
Mailing Address - Country:US
Mailing Address - Phone:530-219-1685
Mailing Address - Fax:
Practice Address - Street 1:7811 LIGHT FIGHTER DR APT C
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80902-4644
Practice Address - Country:US
Practice Address - Phone:530-219-1685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-157738174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN