MEDICARE: MRS. KATINA M WONG 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	:	1740744325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATINA M WONG IBCLC

Provider Business Mailing Address
First Line	:	PO BOX 161621
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78716-1621
Country	:	US
Telephone Number	:	512-651-9360
Fax Number	:

Provider Business Practice Location Address
First Line	:	10619 PLUCHEA CV
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78733-5721
Country	:	US
Telephone Number	:	703-244-9216
Fax Number	:

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

Provider Enumeration Date	:	01/28/2019
Last Update Date	:	01/28/2019

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