Healthcare Provider Details

I. General information

NPI: 1720031453
Provider Name (Legal Business Name): KATHRYN TANIS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

883 LEAD AVE SE STE A
ALBUQUERQUE NM
87102-3644
US

IV. Provider business mailing address

9512 ALLANDE RD NE
ALBUQUERQUE NM
87109-6618
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-8820
  • Fax: 505-246-9421
Mailing address:
  • Phone: 505-299-2148
  • Fax: 505-299-2148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberCNP00550
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: