Healthcare Provider Details

I. General information

NPI: 1316121379
Provider Name (Legal Business Name): TANYA LYNNE CILLESSEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 MONTGOMERY BLVD NE SUITE 4
ALBUQUERQUE NM
87109-1217
US

IV. Provider business mailing address

PO BOX 46123
RIO RANCHO NM
87174
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-9882
  • Fax: 505-881-4838
Mailing address:
  • Phone: 505-872-9882
  • Fax: 505-881-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1376
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: