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General NPI Number Information
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NPI Number | 1821459553
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Entity Type | Individual
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Provider Name | TATYANA N FORMUZAL PT
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Gender | Female
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Dates
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Enumeration Date | 03/08/2016
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Last Update Date | 07/03/2022
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Provider Practice Location Address
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Address Line | 5810 JAMESON CT STE 1
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City | CARMICHAEL
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State | CA
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Zip | 95608-0881
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Country | US
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Telephone | 916-979-0621
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Fax |
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Provider Business Mailing Address
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Address Line | 12260 VINEYARD HILL CT
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City | ELK GROVE
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State | CA
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Zip | 95624-9531
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Country | US
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Telephone |
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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 | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | PT291118
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT291118
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License Number State | CA
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