Provider Demographics
NPI:1669819595
Name:BRUCKER, AMY TANZILLO (IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:TANZILLO
Last Name:BRUCKER
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 1:2313 JACKSON PKWY
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-6914
Mailing Address - Country:US
Mailing Address - Phone:202-437-2490
Mailing Address - Fax:
Practice Address - Street 1:2313 JACKSON PKWY
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-6914
Practice Address - Country:US
Practice Address - Phone:202-437-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-02
Last Update Date:2013-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11151036174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN