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General NPI Number Information
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NPI Number | 1144926049
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Entity Type | Individual
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Provider Name | AUDREY JOHANNA Y TAN
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Gender | Female
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Dates
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Enumeration Date | 02/01/2023
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Last Update Date | 02/01/2023
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Provider Practice Location Address
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Address Line | 517 S A ST
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City | MADERA
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State | CA
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Zip | 93638-3806
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Country | US
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Telephone | 714-390-8761
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Fax |
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Provider Business Mailing Address
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Address Line | 3149 ANTONIO AVE
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City | CLOVIS
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State | CA
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Zip | 93619-8907
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Country | US
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Telephone | 714-390-8761
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 11003
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License Number State | CA
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