Healthcare Provider Details

I. General information

NPI: 1932437076
Provider Name (Legal Business Name): TANYA KAILATH GNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10690 SAN PABLO AVE
EL CERRITO CA
94530-2620
US

IV. Provider business mailing address

10690 SAN PABLO AVE # CA
EL CERRITO CA
94530-2620
US

V. Phone/Fax

Practice location:
  • Phone: 916-813-5212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number19491
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number277871
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: