Healthcare Provider Details

I. General information

NPI: 1053919084
Provider Name (Legal Business Name): TAMRA ELLEN ST JOHN LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 N B ST STE E
SACRAMENTO CA
95811-0326
US

IV. Provider business mailing address

171 BALBOA AVE
SAN JOSE CA
95116-1310
US

V. Phone/Fax

Practice location:
  • Phone: 916-378-8266
  • Fax:
Mailing address:
  • Phone: 419-260-3262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number713484
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: