Provider Demographics
NPI:1285985622
Name:MASSILLON, TERESA LYNN DILLEN (IBCLC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN DILLEN
Last Name:MASSILLON
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 1:1530 DOLORES ST
Mailing Address - Street 2:APT 3
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4935
Mailing Address - Country:US
Mailing Address - Phone:415-821-2298
Mailing Address - Fax:
Practice Address - Street 1:1530 DOLORES ST
Practice Address - Street 2:APT 3
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4935
Practice Address - Country:US
Practice Address - Phone:415-821-2298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10921004174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN