Healthcare Provider Details

I. General information

NPI: 1619364742
Provider Name (Legal Business Name): TANYA LLANQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 S 84TH ST
LA VISTA NE
68128-2127
US

IV. Provider business mailing address

6901 S 84TH ST
LA VISTA NE
68128-2127
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number111778
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: