Healthcare Provider Details

I. General information

NPI: 1184593709
Provider Name (Legal Business Name): LE VENA TAN RD, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 W SHAW AVE STE 106
FRESNO CA
93711-3412
US

IV. Provider business mailing address

1853 EMPRESS LN
TURLOCK CA
95382-8707
US

V. Phone/Fax

Practice location:
  • Phone: 559-451-0460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-306840
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86329279
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: