Healthcare Provider Details

I. General information

NPI: 1740864271
Provider Name (Legal Business Name): TAMARA JEAN HITCHCOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAMARA JEAN JOHN

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11262 CAMPUS ST
LOMA LINDA CA
92350-1727
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4000
  • Fax:
Mailing address:
  • Phone: 909-558-4923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number706703
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95018405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: