Provider Demographics
NPI:1558887398
Name:TRUNICK, IDA CAROLINE SUZANNE (MA, IBCLC)
Entity Type:Individual
Prefix:MS
First Name:IDA
Middle Name:CAROLINE SUZANNE
Last Name:TRUNICK
Suffix:
Gender:F
Credentials:MA, IBCLC
Other - Prefix:MS
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:TRUNICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, IBCLC
Mailing Address - Street 1:15060 HALEY HOLW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-4454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 CAMINO LA COSTA
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-3930
Practice Address - Country:US
Practice Address - Phone:512-684-1744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
L-35230OtherIBCLE