Healthcare Provider Details

I. General information

NPI: 1487414298
Provider Name (Legal Business Name): FAIR ANTONETTE TANADA ESPELITA RN, CPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 RAYNOR ST
COLTON CA
92324-7520
US

IV. Provider business mailing address

1053 RAYNOR ST
COLTON CA
92324-7520
US

V. Phone/Fax

Practice location:
  • Phone: 909-735-1121
  • Fax:
Mailing address:
  • Phone: 909-735-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number671069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: