MEDICARE: TINA ELIZABETH SCHROEDER IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)

General Provider Information

NPI Number	:	1366198939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA ELIZABETH SCHROEDER IBCLC

Provider Business Mailing Address
First Line	:	PO BOX 2681
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-9122
Country	:	US
Telephone Number	:	208-912-5682
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 E STATE ST
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-6081
Country	:	US
Telephone Number	:	208-912-5682
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2022
Last Update Date	:	02/23/2022

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