Healthcare Provider Details

I. General information

NPI: 1114800232
Provider Name (Legal Business Name): TANYA KINNEY RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

295 PARKVIEW DR
BLUE RIDGE VA
24064-1614
US

V. Phone/Fax

Practice location:
  • Phone: 540-797-8753
  • Fax:
Mailing address:
  • Phone: 567-274-7503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-319350
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: