=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053463612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUTH AYUKONSOH TANYI RN, MSN, NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 07/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 577 N D ST SUITE # 101
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92401-1324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-386-1500
-----------------------------------------------------
Fax | 909-386-1588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 577 N D ST SUITE # 101
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92401-1324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-386-1500
-----------------------------------------------------
Fax | 909-386-1588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 15272
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------