Provider Demographics
NPI:1083122964
Name:CARPENTER, TONJA DENISE (IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:TONJA
Middle Name:DENISE
Last Name:CARPENTER
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 1:2316 GORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2862
Mailing Address - Country:US
Mailing Address - Phone:254-753-1987
Mailing Address - Fax:
Practice Address - Street 1:1525 AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1711
Practice Address - Country:US
Practice Address - Phone:254-753-1987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-13
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-126587174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN