Healthcare Provider Details

I. General information

NPI: 1124767264
Provider Name (Legal Business Name): TANYA FERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

IV. Provider business mailing address

731 PUEBLO AVE
NAPA CA
94558-3562
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-8181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number722245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: