Provider Demographics
NPI:1609152990
Name:MICKUS, TARYN LYNDS (IBCLC)
Entity Type:Individual
Prefix:
First Name:TARYN
Middle Name:LYNDS
Last Name:MICKUS
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 1:452 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3719
Mailing Address - Country:US
Mailing Address - Phone:510-999-5055
Mailing Address - Fax:
Practice Address - Street 1:452 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-3719
Practice Address - Country:US
Practice Address - Phone:510-999-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11116142174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN