Provider Demographics
NPI:1043813280
Name:TANARE, MARSHA SALLY ORTALEZA (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARSHA SALLY
Middle Name:ORTALEZA
Last Name:TANARE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3631 CRENSHAW BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-4869
Mailing Address - Country:US
Mailing Address - Phone:323-732-0100
Mailing Address - Fax:
Practice Address - Street 1:3631 CRENSHAW BLVD STE 109
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-4869
Practice Address - Country:US
Practice Address - Phone:323-732-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016015363LF0000X
CA95160696163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse