Healthcare Provider Details

I. General information

NPI: 1255043519
Provider Name (Legal Business Name): MONNIE KATE TIMS IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE TIMS IBCLC

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 AUSTIN CENTER BLVD STE 225
AUSTIN TX
78731-3293
US

IV. Provider business mailing address

513 SADDLEBACK RD
AUSTIN TX
78737-4572
US

V. Phone/Fax

Practice location:
  • Phone: 512-846-6455
  • Fax:
Mailing address:
  • Phone: 817-683-1106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-310420
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: