Healthcare Provider Details

I. General information

NPI: 1790498277
Provider Name (Legal Business Name): KATHRYN JOANNA LUNDSTRUM CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE LUNDSTRUM CLC

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 MAIN DR
FAYETTEVILLE AR
72704-5292
US

IV. Provider business mailing address

134 BLACKJACK RD
GREENBRIER AR
72058-9706
US

V. Phone/Fax

Practice location:
  • Phone: 479-485-1215
  • Fax:
Mailing address:
  • Phone: 501-652-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number335914
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: