Healthcare Provider Details

I. General information

NPI: 1659572592
Provider Name (Legal Business Name): TYRA MONIQUE VILLALOBOS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 N FINE AVE STE 116 HUMAN RESOURCES
FRESNO CA
93727-1528
US

IV. Provider business mailing address

2025 DIVISADERO ST #100
FRESNO CA
93701-2013
US

V. Phone/Fax

Practice location:
  • Phone: 559-457-5231
  • Fax: 559-457-5896
Mailing address:
  • Phone: 559-457-5500
  • Fax: 559-457-5896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: