Provider Demographics
NPI:1164812467
Name:PHANTHANUSORN, TARYN LEE (IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:TARYN
Middle Name:LEE
Last Name:PHANTHANUSORN
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 1:23315 VIA BAHIA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2115
Mailing Address - Country:US
Mailing Address - Phone:949-677-7510
Mailing Address - Fax:
Practice Address - Street 1:23315 VIA BAHIA
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-2115
Practice Address - Country:US
Practice Address - Phone:949-677-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11242387174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN