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General NPI Number Information
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NPI Number | 1639420789
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Entity Type | Individual
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Provider Name | TAMARA VESTAL RN153164
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Gender | Female
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Dates
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Enumeration Date | 09/28/2012
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Last Update Date | 09/28/2012
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Provider Practice Location Address
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Address Line | 101 CIVIC CENTER LN
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5607
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Country | US
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Telephone | 928-855-8185
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Fax |
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Provider Business Mailing Address
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Address Line | 3410 POPPY TRAIL DR
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86406-7827
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Country | US
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Telephone | 928-208-3673
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN153164
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License Number State | AZ
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