Healthcare Provider Details

I. General information

NPI: 1760862338
Provider Name (Legal Business Name): TABATHA DAWN WUNSCHE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 TRAINER WAY
RENO NV
89512-2593
US

IV. Provider business mailing address

2015 TRAINER WAY
RENO NV
89512-2593
US

V. Phone/Fax

Practice location:
  • Phone: 702-622-2484
  • Fax:
Mailing address:
  • Phone: 702-622-2484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number251S00000X
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: