Healthcare Provider Details

I. General information

NPI: 1134065527
Provider Name (Legal Business Name): CAMILLE TIBI MBAH TANGWAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 PICKERINGTON PONDS DR
PICKERINGTON OH
43147-9970
US

IV. Provider business mailing address

207 PICKERINGTON PONDS DR (651) 434-3104
PICKERINGTON OH
43147-9970
US

V. Phone/Fax

Practice location:
  • Phone: 651-434-3104
  • Fax: 651-434-3104
Mailing address:
  • Phone: 651-434-3104
  • Fax: 651-434-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.534160
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: