Provider Demographics
NPI:1649020249
Name:ALSUP, TRACY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ALSUP
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 SKLAR ST
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0805
Mailing Address - Country:US
Mailing Address - Phone:505-944-5825
Mailing Address - Fax:
Practice Address - Street 1:25255 CABOT RD STE 112
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5507
Practice Address - Country:US
Practice Address - Phone:505-944-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA834555163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant