Provider Demographics
NPI:1083239222
Name:TAN, RYCELONIA (RN)
Entity Type:Individual
Prefix:
First Name:RYCELONIA
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 VINCENTE AVE
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2447
Mailing Address - Country:US
Mailing Address - Phone:818-640-6741
Mailing Address - Fax:
Practice Address - Street 1:3863 VINCENTE AVE
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2447
Practice Address - Country:US
Practice Address - Phone:818-640-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA739957163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse