Provider Demographics
NPI:1003053968
Name:BULLWINKLE, TANYA ELAN (LM)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:ELAN
Last Name:BULLWINKLE
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 HOWARD HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-9570
Mailing Address - Country:US
Mailing Address - Phone:707-407-7566
Mailing Address - Fax:
Practice Address - Street 1:3225 TIMBER FALL CT
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4892
Practice Address - Country:US
Practice Address - Phone:707-442-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM238176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife