Provider Demographics
NPI:1861201261
Name:GONZALES, TIFFANY ANN (IBCLC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:GONZALES
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 YARROW DR
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-8768
Mailing Address - Country:US
Mailing Address - Phone:818-414-4866
Mailing Address - Fax:
Practice Address - Street 1:1301 YARROW DR
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-8768
Practice Address - Country:US
Practice Address - Phone:818-414-4866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-01
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-317397174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN