MEDICARE: TIFFANY KIMBLE CLC

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)		IL

General Provider Information

NPI Number	:	1770438939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY KIMBLE CLC

Provider Business Mailing Address
First Line	:	648 LARKSPUR LN
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-1770
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19710 GOVERNORS HWY STE 5
Second Line	:
City	:	FLOSSMOOR
State	:	IL
Zip	:	60422-2081
Country	:	US
Telephone Number	:	708-843-1540
Fax Number	:

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

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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Directions to “ TIFFANY KIMBLE CLC” Practice Location

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