Provider Demographics
NPI:1164835526
Name:KNUTSON, TANJA (IBCLC)
Entity Type:Individual
Prefix:
First Name:TANJA
Middle Name:
Last Name:KNUTSON
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 1:2121 SEA EAGLE VW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-5382
Mailing Address - Country:US
Mailing Address - Phone:512-720-9688
Mailing Address - Fax:
Practice Address - Street 1:2121 SEA EAGLE VW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-5382
Practice Address - Country:US
Practice Address - Phone:512-720-9688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZL-28104174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN