Provider Demographics
NPI:1790261626
Name:GAUDLIP, TRACY DARLENE (IBCLC, LIC LC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DARLENE
Last Name:GAUDLIP
Suffix:
Gender:F
Credentials:IBCLC, LIC LC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 BOULEVARD SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-3464
Mailing Address - Country:US
Mailing Address - Phone:404-454-9751
Mailing Address - Fax:
Practice Address - Street 1:575 BOULEVARD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-3464
Practice Address - Country:US
Practice Address - Phone:404-454-9751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALC000086174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN