Provider Demographics
NPI:1043825193
Name:TAVERA, ADALJIZA (PMHNP, FNP)
Entity Type:Individual
Prefix:MS
First Name:ADALJIZA
Middle Name:
Last Name:TAVERA
Suffix:
Gender:F
Credentials:PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31231
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0231
Mailing Address - Country:US
Mailing Address - Phone:323-947-4901
Mailing Address - Fax:
Practice Address - Street 1:1225 W 190TH ST STE 280
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4305
Practice Address - Country:US
Practice Address - Phone:310-515-8113
Practice Address - Fax:310-538-2102
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95013634363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily