Healthcare Provider Details

I. General information

NPI: 1588360127
Provider Name (Legal Business Name): MARILETH TAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20211 W VALLEY BLVD
TEHACHAPI CA
93561-6748
US

IV. Provider business mailing address

20211 W VALLEY BLVD
TEHACHAPI CA
93561-6748
US

V. Phone/Fax

Practice location:
  • Phone: 626-764-5296
  • Fax:
Mailing address:
  • Phone: 661-822-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95020289
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: