Provider Demographics
NPI:1679340202
Name:MASSIE, ANNICE ROSE (IBCLC)
Entity type:Individual
Prefix:
First Name:ANNICE
Middle Name:ROSE
Last Name:MASSIE
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 1:7321 TICONDEROGA DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-4158
Mailing Address - Country:US
Mailing Address - Phone:775-856-9225
Mailing Address - Fax:
Practice Address - Street 1:7321 TICONDEROGA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-4158
Practice Address - Country:US
Practice Address - Phone:775-856-9225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYL-306846174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN