Provider Demographics
NPI:1073949863
Name:TABONE, BRENDA ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:ANN
Last Name:TABONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S. SEVENTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744
Mailing Address - Country:US
Mailing Address - Phone:626-961-8971
Mailing Address - Fax:
Practice Address - Street 1:160 S. SEVENTH AVENUE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744
Practice Address - Country:US
Practice Address - Phone:626-961-8971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23529363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA471870979OtherBRENDA TABONE (TIN)