Healthcare Provider Details

I. General information

NPI: 1487591483
Provider Name (Legal Business Name): TYNESHA WADE CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

IV. Provider business mailing address

13064 THICKET PL
CORONA CA
92883-6347
US

V. Phone/Fax

Practice location:
  • Phone: 714-203-2181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number95038465
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: