Provider Demographics
NPI:1326634296
Name:LANCE, TERESA (IBCLC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LANCE
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 1:9807 N FM 620
Mailing Address - Street 2:APT 17110
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726
Mailing Address - Country:US
Mailing Address - Phone:512-660-0850
Mailing Address - Fax:
Practice Address - Street 1:3408 GRAYBUCK RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-1031
Practice Address - Country:US
Practice Address - Phone:512-660-0850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
L-302792174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty