Provider Demographics
NPI:1053042630
Name:ROSS-PHALEN, TANA
Entity Type:Individual
Prefix:
First Name:TANA
Middle Name:
Last Name:ROSS-PHALEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 MARINA DR
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8819
Mailing Address - Country:US
Mailing Address - Phone:304-988-4200
Mailing Address - Fax:
Practice Address - Street 1:1023 MARINA DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8819
Practice Address - Country:US
Practice Address - Phone:304-988-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker