Provider Demographics
NPI:1093799470
Name:KELLENBERGER, TANYA ANN
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:ANN
Last Name:KELLENBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TANYA
Other - Middle Name:ANN
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2810 130TH PLACE S.E.
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208
Mailing Address - Country:US
Mailing Address - Phone:206-767-1387
Mailing Address - Fax:
Practice Address - Street 1:2810 130TH PL SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6747
Practice Address - Country:US
Practice Address - Phone:206-767-1387
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00041922183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician