Provider Demographics
NPI:1790498277
Name:LUNDSTRUM, KATHRYN JOANNA (CLC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JOANNA
Last Name:LUNDSTRUM
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:LUNDSTRUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CLC
Mailing Address - Street 1:134 BLACKJACK RD
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-9706
Mailing Address - Country:US
Mailing Address - Phone:501-652-1441
Mailing Address - Fax:
Practice Address - Street 1:2211 MAIN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5292
Practice Address - Country:US
Practice Address - Phone:479-485-1215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR335914174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN