Provider Demographics
NPI:1154679462
Name:RAGLAND, TANISHA RENEE (RN)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:RENEE
Last Name:RAGLAND
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 1:2830 S KERCKHOFF AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-6626
Mailing Address - Country:US
Mailing Address - Phone:585-721-5686
Mailing Address - Fax:
Practice Address - Street 1:2830 S KERCKHOFF AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-6626
Practice Address - Country:US
Practice Address - Phone:585-721-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY655565163W00000X
CA95017916363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse