MEDICARE: TIFFANY WANGARD LACTATION CONSULTANT

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	:	1942963970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY WANGARD LACTATION CONSULTANT

Provider Business Mailing Address
First Line	:	22653 E DESERT SPOON DR
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-8545
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	22653 E DESERT SPOON DR
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-8545
Country	:	US
Telephone Number	:	602-621-7864
Fax Number	:

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

Provider Enumeration Date	:	10/17/2021
Last Update Date	:	11/02/2021

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