Healthcare Provider Details

I. General information

NPI: 1215757521
Provider Name (Legal Business Name): XXX TENEBROSO CRISENCIO TAMBIEN REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CRISENCIO TENEBROSO REGISTERED NURSE

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUFFALO PSYCHIATRIC CENTER 400 FOREST AVENUE
BUFFALO NY
14213
US

IV. Provider business mailing address

36 WILKERSON STREET
THOROLD ZZ - FOREIGN COUNTRIES
L2V0G4
CA

V. Phone/Fax

Practice location:
  • Phone: 716-816-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number75917801
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: