Provider Demographics
NPI:1104213602
Name:TANENBERG, LONNIE
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:
Last Name:TANENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 SAN ANSELMO AVE
Mailing Address - Street 2:APT B
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1863
Mailing Address - Country:US
Mailing Address - Phone:415-685-4493
Mailing Address - Fax:
Practice Address - Street 1:1516 SAN ANSELMO AVE
Practice Address - Street 2:APT B
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-1863
Practice Address - Country:US
Practice Address - Phone:415-685-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer