Provider Demographics
NPI:1316347883
Name:KOONTZ, TATIANA (LM, CPM)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 VALLEY CENTRE DR # 705-246
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3320
Mailing Address - Country:US
Mailing Address - Phone:858-221-6040
Mailing Address - Fax:
Practice Address - Street 1:3830 VALLEY CENTRE DR # 705-246
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130
Practice Address - Country:US
Practice Address - Phone:858-221-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2019-03-28
Deactivation Date:2019-03-12
Deactivation Code:
Reactivation Date:2019-03-27
Provider Licenses
StateLicense IDTaxonomies
374J00000X
CA559176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula