Healthcare Provider Details

I. General information

NPI: 1285911214
Provider Name (Legal Business Name): TEJON WOODS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 W REDLANDS BLVD
REDLANDS CA
92373-8054
US

IV. Provider business mailing address

4262 LYND AVE
ARCADIA CA
91006-5834
US

V. Phone/Fax

Practice location:
  • Phone: 909-335-3026
  • Fax:
Mailing address:
  • Phone: 916-747-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21303
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number21303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: