Provider Demographics
NPI:1699210211
Name:WILLIAMS, TRACY LYNN (IBCLC, CLC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:IBCLC, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-3400
Mailing Address - Country:US
Mailing Address - Phone:314-606-0717
Mailing Address - Fax:
Practice Address - Street 1:1122 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-3400
Practice Address - Country:US
Practice Address - Phone:314-606-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
MOALPP-231171174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN