Provider Demographics
NPI:1104346097
Name:JOHNSON, LEASTER TRUSCLAIR (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:LEASTER
Middle Name:TRUSCLAIR
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4717 N HUSON ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-4418
Mailing Address - Country:US
Mailing Address - Phone:253-208-1886
Mailing Address - Fax:
Practice Address - Street 1:3629 S D ST # MS 1100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-6813
Practice Address - Country:US
Practice Address - Phone:253-798-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAL-83604163WL0100X
171M00000X
WARN00110931163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator