Healthcare Provider Details

I. General information

NPI: 1134740244
Provider Name (Legal Business Name): TAMARA SUE STANIC RN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N. FRESNO STREET, SUITE 370
FRESNO CA
93701
US

IV. Provider business mailing address

2940 SAN JOSE AVE
CLOVIS CA
93611-6972
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-4543
  • Fax: 559-459-1524
Mailing address:
  • Phone: 559-977-6899
  • Fax: 559-459-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number377376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: